Date Modified: May 29, 2014 Clinical Quality s for PQRS
# Domain Type Denominator Numerator Denominator Exclusions/Exceptions Rationale QCDR-1 QCDR-2 Patient Safety 102 Efficiency and Cost Reduction QCDR-3 Efficiency and Cost Reduction 104 194 250 QCDR-4 QCDR-5 QCDR-6 Prostate Biopsy: Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy Unplanned Hospital Admission within 30 Days of TRUS Biopsy: Percentage of biopsies where patients aged 30 years and had an unplanned hospital admission within 30 days of biopsy Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a CT scan performed at any time since diagnosis of Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist) Oncology: Cancer Stage Documented: Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period Radical Prostatectomy Pathology Reporting: Percentage of radical prostatectomy pathology reports that include the pt category, the pn category, the Gleason score and a statement about margin status Prostate Cancer: Proportion of patients with low-risk receiving active surveillance Prostate Cancer: Percentage of cases with a length of stay > 2 days Unplanned Hospital Readmission within 30 Days of Radical Prostatectomy: Percentage of patients aged 30 years and who had an unplanned hospital readmission within 30 days of principal procedure # of prostate biopsies for patients aged 30 or # of prostate biopsies for patients aged 30 or PQRS See cancer patients 30 years or receiving brachytherapy, EBRT, RP, or cryotherapy PQRS See PQRS See PQRS See cancer patients 30 or # of patients aged 30 or who underwent a radical prostatectomy as treatment for # of radical prostatectomies for patients aged 30 or # of biopsies where a compliant antibiotic regimen was given # of biopsies where a hospital admission resulted within 30 days of the procedure PQRS See # of low risk prostate cancer patients receiving brachytherapy, EBRT, RP, or cryotherapy who did not have a CT scan since diagnosis of prostate cancer PQRS See PQRS See PQRS See cancer patients on active surveillance # of patients with a length of stay > 2 days after radical prostatectomy # of radical prostatectomies where a hospital admission resulted within 30 days of the procedure Non-TRUS biopsies; biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment Biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment age; patients receiving an alternate form of treatment from those specified; patients that have had prior treatment age; patients that have had prior treatment age; patients that have had prior treatment Prostatectomies performed in patients < 30 years of age; patients that have had prior treatment Evidence-based care Metric of safety of medical care PQRS See Metric of appropriate resource utilization PQRS See PQRS See PQRS See Metric of patientcentered decision making Metric of appropriate resource utilization Metric of safety of medical care Michigan Urological Surgery Improvement Collaborative () QCDR Page 2
Non-PQRS #1 ( QCDR-1): Prostate Biopsy Antibiotic Compliance Prostate Biopsy: Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy Patient safety # of biopsies where a compliant antibiotic regimen was given # of prostate biopsies for patients aged 30 or Excludes non-trus biopsies; biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment for Evidence-based care Non-PQRS # 2 ( QCDR-2): Unplanned Hospital Admissions within 30 days of TRUS Biopsy Percentage of biopsies where patients aged 30 years and had an unplanned hospital admission within 30 days of biopsy clinical care # of biopsies where a hospital admission resulted within 30 days of the procedure # of prostate biopsies for patients aged 30 or Excludes non-trus biopsies; biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment for Metric of safety of medical care Michigan Urological Surgery Improvement Collaborative () QCDR Page 3
Non-PQRS # 3 ( QCDR-3): Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients Percentage of patients, regardless of age, with a diagnosis of at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of Efficiency and cost reduction # of low risk patients receiving brachytherapy, EBRT, RP, or cryotherapy who did not have a CT scan since diagnosis of # of low-risk patients 30 years or receiving brachytherapy, EBRT, RP, or cryotherapy Excludes patients < 30 years of age; patients receiving an alternate form of treatment from those specified; patients that have had prior treatment Metric of appropriate resource utilization Non-PQRS # 4 ( QCDR-4): Prostate Cancer: Proportion of Patients with Low-Risk Prostate Cancer Receiving Active Surveillance Proportion of patients with low-risk receiving active surveillance clinical care # of low-risk patients on active surveillance # of prostate biopsies for patients aged 30 or Excludes patients < 30 years of age; patients that have had prior treatment Metric of patient-centered decision making Michigan Urological Surgery Improvement Collaborative () QCDR Page 4
Non-PQRS # 5 ( QCDR-5): Prostate Cancer: Percentage of Prostate Cancer Cases with a Length of Stay > 2 Days Percentage of radical prostatectomy cases with a length of stay > 2 days clinical care # of patients with a length of stay > 2 days after radical prostatectomy # of patients aged 30 or who underwent a radical prostatectomy as treatment Excludes patients < 30 years of age; patients that have had prior treatment Metric of appropriate resource utilization Non-PQRS # 6 ( QCDR-6): Unplanned Hospital Readmission within 30 Days of Radical Prostatectomy Percentage of patients aged 30 years and who had an unplanned hospital readmission within 30 days of principal procedure clinical care # of radical prostatectomies where a hospital admission resulted within 30 days of the procedure # of radical prostatectomies for patients aged 30 or Excludes prostatectomies performed in patients < 30 years of age; patients that have had prior treatment Metric of safety of medical care Michigan Urological Surgery Improvement Collaborative () QCDR Page 5