Year 5 Specifications- Clinical conditions and measures for
reporting and incentives

Acute Myocardial Infarction (AMI)

1. Aspirin at arrival (v1)

2. Aspirin prescribed at discharge (v1)

3. ACEI or ARB for Left Ventricular Systolic Dysfunction (LVSD) (v1)

4. Adult smoking cessation advice counseling (v1)

5. Beta-Blocker prescribed at discharge (v1)

6. Beta-Blocker at arrival (v1)

7. Fibrinolytic Therapy received within 30 minutes of hospital arrival (v1)

8. Primary Percutaneous Coronary Intervention (PCI) received within 90 minutesof Hospital Arrival (v1)

9. Inpatient Mortality (v1)

Acute Myocardial Infarction (AMI)

Test Measures

10. CMS 30-day Mortality Rate

11. Readmission to same facility within 30 days of Discharge

12. AHRQ Patient Safety Composite Measure

13. Appropriate Care Measure

T1 LDL Cholesterol Assessment (v1)

T2 Lipid Lowering Therapy at Discharge (v1)

T3 CMS 30-Day Readmission Rate (CMS administrative data)

T4 CareScience Complication Measure

Isolated Coronary Artery Bypass Graft (CABG)

14. Aspirin prescribed at discharge (v1)

15. Coronary artery bypass graft using internal mammary artery (IMA) (v1)

16. Prophylactic antibiotic received within 1 hour prior to surgical incision (v1)

17. Prophylactic antibiotic selection for Isolated CABG patients (v1)

18. Prophylactic antibiotics discontinued within 48 Hours after Surgery end time (v1)

19. Inpatient mortality rate

Isolated Coronary Artery Bypass Graft (CABG)

Test Measures

20. Readmission to same facility within 30 days of Discharge

21. AHRQ Patient Safety Composite Measure

22. Appropriate Care Measure

23. AHRQ Inpatient Quality Indicator Post-Procedural Mortality - CABG

T5 Cardiac Surgery Patients with Controlled 6 A.M. Postopertaive Blood Glucose (v1)

T6 Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period (v1)

T7 CareScience Complication Measure

Heart Failure (HF)

24. Left ventricular function (LVF) assessment (v1)

25. Discharge instructions (v1)

26. Angiotension converting enzyme inhibitor (ACEI) or Angiotension receptor blocker (ARB) for Left Ventricular Systolic Dysfunction (LVSD) (v1)

27. Adult smoking cessation advice counseling (v1)

Heart Failure (HF)

Test Measures

28. Readmission to same facility within 30 days of Discharge

29. AHRQ Patient Safety Composite Measure

30. Appropriate Care Score

31. CMS 30-Day Mortality Rate

32. AHRQ Inpatient Quality Indicators In-Hospital Mortality Rate – Heart Failure

T8 CMS 30-Day Readmission Rate

T9 CareScience Complication Measure

Pneumonia (PN)

33. Oxygenation assessment (v1)

34. Initial Antibiotic selection for Community Acquired Pneumonia in Immuno-competent patients (v1)

35. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital (v1)

36. Influenza Vaccination (v1)

37. Pneumococcal Vaccination (v1)

38. Initial antibiotic received within 6 hours of hospital arrival  (v1)

39. Adult smoking cessation advice/ counseling (v1)

Pneumonia (PN)

Test Measures

40. Readmission to same facility within 30 days of Discharge

41. AHRQ Patient Safety Composite Measure

42. Appropriate Care Measure

43. CMS 30-Day Mortality Rate

44. AHRQ Inpatient Quality Indicators In-hospital Mortality – Pneumonia

T10 CMS 30-Day Readmission Rate

T11 CareScience Complication Measure

Hip and Knee Replacement

45. Prophylactic antibiotic received within 1 hour prior to surgical incision (v1)

46. Prophylactic antibiotic selection for hip and knee replacement patients (v1)

47. Prophylactic antibiotics discontinued within 24 Hours after surgery end time (v1)

48. Hip or Knee replacement Patients with Recommended Venous(v1) Thromboembolism Prophylaxis Ordered

49. Hip or Knee replacement Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to surgery to 24 Hours After surgery (v1)

50. CMS Readmission 30 days post discharge (v1)

Hip and Knee Replacement

Test Measures

51. AHRQ Patient Safety Composite Measure

52. Appropriate Care Measure

53. AHRQ Inpatient Quality Indicator Post-Procedural Mortality – Hip or Knee Replacement

T12 Hip or Knee Replacement patients on Beta-Blocker Therapy who Receive Beta-Blocker during Perioperative Period  (v1)

T13 CareScience Complication Measure

Surgical Care Improvement Project (SCIP)

54. Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision. (v1)

55. Prophylactic Antibiotic Selection for Surgical Patients. (v1)

56. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time. (v1)

57. Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (v1)

58. Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery (v1)

Surgical Care Improvement Project (SCIP)

Test Measure

T14 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose. (v1)

T15 Surgery Patients with Appropriate Hair Removal.  (v1)

T16 Colorectal Surgery Patients with Immediate Postoperative Normothermia. (v1)

T17 Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period (v1)

T18 CareScience Complication Measure