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Measure Summaries In Progress

NQMC is currently working on 62 measures that have met the NQMC Inclusion Criteria. Measure titles, and their respective Measure Collections, are listed alphabetically by measure developer.

New reflects measures added to the NQMC work queue within the last 2 weeks.

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A

Agency for Healthcare Research and Quality (2)

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators

New Esophageal resection mortality: percentage of in-hospital deaths per 1,000 discharges with esophageal resection for cancer, ages 18 years and older.

New Pancreatic resection mortality: percentage of in-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older.

American Academy of Dermatology (1)

Melanoma II Physician Performance Measurement Set

Melanoma: percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

American College of Chest Physicians (7)

Quality Indicators for the Evaluation of Patients with Lung Cancer

Lung cancer: percentage of active smokers with lung cancer who have had smoking cessation counseling documented.

Lung cancer: percentage of non-surgical biopsies in patients with clinical stage IV non-squamous non-small cell lung cancer that obtained an adequate amount of tissue for molecular testing.

Lung cancer: percentage of patients with clinical stage IB or higher, but no evidence of metastatic disease, who have had a mediastinal lymph node sampling procedure performed prior to the initiation of curative intent therapy.

Lung cancer: percentage of patients with clinical stage III or IV lung cancer, or neurologic symptoms, who have had brain imaging performed within 3 months prior to the initiation of treatment.

Lung cancer: percentage of patients with evidence of one to three distant metastases who have had an attempt at biopsy confirmation of a site of metastasis, or documentation of a reason that this was not possible or necessary.

Lung cancer: percentage of patients with lung cancer in whom a performance status measure is documented prior to treatment.

Lung cancer: percentage of patients with lung cancer who have an American Joint Committee on Cancer (AJCC) current edition clinical lung cancer stage documented prior to curative intent therapy.

American Society for Radiation Oncology (1)

External Beam Radiotherapy for Bone Metastases

New External beam radiotherapy (EBRT) for bone metastases: percentage of patients, regardless of age, with a diagnosis of bone metastases and no history of previous radiation who receive EBRT with an acceptable fractionation scheme as defined by the guideline.

American Society of Hematology (13)

Myelodysplastic Syndromes Measure Set

Myelodysplastic syndromes (MDS): percentage of higher-risk MDS patients receiving azacitidine or decitabine.

Myelodysplastic syndromes (MDS): percentage of MDS patients for whom an established pathologic classification/risk prognostication system was used to help plan therapeutic options.

Myelodysplastic syndromes (MDS): percentage of MDS patients presenting with anemia who had a serum erythropoietin level less than or equal to 500 mU/ml prior to receiving erythropoietin/darbepoetin therapy.

Myelodysplastic syndromes (MDS): percentage of MDS patients presenting with anemia who had evidence of adequate iron stores within 60 days prior to receiving erythropoietin/darbepoetin therapy.

Myelodysplastic syndromes (MDS): percentage of MDS patients who are candidates for allogeneic stem cell transplant receiving irradiated transfusion products.

Myelodysplastic syndromes (MDS): percentage of MDS patients whose baseline diagnostic evaluation includes cytogenetic testing on bone marrow by standard karyotyping methods.

Myelodysplastic syndromes (MDS): percentage of patients with a diagnosis of MDS whose eligibility for a clinical trial was checked at least once a year.

Non-Hodgkin Lymphoma Measure Set

Non-Hodgkin lymphoma: percent of lymphoma patients advised to receive immunization/vaccination aligned with CDC recommendations.

Non-Hodgkin lymphoma: percent of lymphoma patients assigned a specific stage using Ann Arbor system including presence/absence of B symptoms AND having bone marrow biopsy or documentation why bone marrow biopsy was unnecessary or contraindicated.

Non-Hodgkin lymphoma: percent of lymphoma patients of childbearing age who received treatment for lymphoma and who were offered fertility counseling prior to starting treatment OR documentation in the medical record why such counseling was unnecessary.

Non-Hodgkin lymphoma: percent of lymphoma patients treated with anti-CD20 monoclonal antibody-containing regimens and tested for hepatitis B prior to medication administration.

Non-Hodgkin lymphoma: percent of lymphoma patients who are 65 years old or older and receiving CHOP +/-R, prescribed prophylactic myeloid growth factor (MGF).

Non-Hodgkin lymphoma: percent of patients with lymphoma whose initial lymphoma diagnosis was established by one of the following: incisional or excisional biopsy AND immunohistochemical characterization, OR core needle biopsy AND appropriate ancillary techniques employed.

C

Centers for Medicare & Medicaid Services (3)

Hospital Outpatient Department Quality Measures

Imaging efficiency: percentage of patients with mammography screening studies that are followed by a diagnostic mammography, ultrasound or MRI of the breast in an outpatient or office setting within 45 days.

Outpatient colonoscopy: facility level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy.

National Hospital Inpatient Quality Measures

Sepsis: percentage of inpatients age 18 and over with a diagnosis of severe sepsis or septic shock who had the following performed, consistent with the Surviving Sepsis Campaign guidelines: measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.

M

MN Community Measurement (4)

Symptom Control during Chemotherapy

Symptom control during chemotherapy: percentage of chemotherapy patients 18 years of age and older for whom a symptom severity assessment was completed during days 5 to 15 of the chemotherapy cycle using the specified patient-reported outcome tool.

Symptom control during chemotherapy: percentage of chemotherapy patients 18 years of age and older whose constipation severity rating was none or mild during days 5 to 15 of the chemotherapy cycle.

Symptom control during chemotherapy: percentage of chemotherapy patients 18 years of age and older whose nausea severity rating was none or mild during days 5 to 15 of the chemotherapy cycle.

Symptom control during chemotherapy: percentage of chemotherapy patients 18 years of age and older whose pain severity rating was none or mild during days 5 to 15 of the chemotherapy cycle.

N

NHS Scotland (19)

Cancer Quality Performance Indicators (QPIs)

New Endometrial cancer: proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery.

New Endometrial cancer: proportion of patients with endometrial cancer who are discussed at a multidisciplinary team (MDT) meeting before definitive treatment.

New Endometrial cancer: proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis prior to first treatment.

New Endometrial cancer: proportion of patients with endometrial cancer who undergo total hysterectomy and bilateral salpingo-oophorectomy (TH/BSO).

New Endometrial cancer: proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant vaginal brachytherapy.

New Endometrial cancer: proportion of patients with stage IV endometrial cancer receiving chemotherapy.

New Ovarian cancer: proportion of epithelial ovarian cancer patients who receive platinum-based chemotherapy, either in combination or as a single agent.

New Ovarian cancer: proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) who have less then 1 cm macroscopic residual disease following surgery.

New Ovarian cancer: proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) who have no macroscopic residual disease following surgery.

New Ovarian cancer: proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) undergoing delayed primary surgery following neo-adjuvant chemotherapy where optimal cytoreduction is achieved (residual disease less than 1 cm).

New Ovarian cancer: proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) undergoing delayed primary surgery following neo-adjuvant chemotherapy.

New Ovarian cancer: proportion of patients with early stage epithelial ovarian cancer (FIGO Stage 1) undergoing primary surgery and operated on by a gynaecological oncologist, who have an adequate staging operation involving total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy and washings.

New Ovarian cancer: proportion of patients with early stage epithelial ovarian cancer (FIGO Stage 1) undergoing primary surgery who have an adequate staging operation involving total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy and washings.

New Ovarian cancer: proportion of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis performed prior to starting definitive treatment.

New Ovarian cancer: proportion of patients with epithelial ovarian cancer having a histo/cytological diagnosis recorded prior to starting neo-adjuvant chemotherapy with confirmation obtained by histology.

New Ovarian cancer: proportion of patients with epithelial ovarian cancer having a histo/cytological diagnosis recorded prior to starting neo-adjuvant chemotherapy.

New Ovarian cancer: proportion of patients with epithelial ovarian cancer undergoing pelvic clearance surgery having a complete pathology report as defined by the Royal College of Pathologists.

New Ovarian cancer: proportion of patients with epithelial ovarian cancer who are discussed at a multi-disciplinary team (MDT) meeting before definitive treatment.

New Ovarian cancer: proportion of patients with Stage 1 epithelial ovarian cancer having Risk of Malignancy Index (RMI) assessed and recorded in their notes prior to any definitive surgical intervention.

S

Sandsdalen, Tuva, MNS, CCRN, RNT; Wilde-Larsson, Bodil, PhD, RNT (7)

Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC)

Palliative care: mean score on the "Best possible help to take care of personal hygiene" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Best possible medical care" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Identity-Oriented Approach" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Medical-Technical Competence" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Physical-Technical Conditions" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Pleasant and secure atmosphere on the ward" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Socio-Cultural Atmosphere" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

U

University of North Carolina at Chapel Hill (5)

Palliative Care and End-of-Life Care

Palliative and end-of-life care: percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.

Palliative and end-of-life care: percentage of hospice or palliative care patients who were screened for dyspnea during the hospice admission evaluation/palliative care initial encounter.

Palliative and end-of-life care: percentage of hospice or palliative care patients who were screened for pain during the hospice admission evaluation/palliative care initial encounter.

Palliative and end-of-life care: percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.

Palliative and end-of-life care: percentage of patients with chart documentation of preferences for life sustaining treatments.

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