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Measure Summaries In Progress

NQMC is currently working on 115 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

American Academy of Dermatology (2)

Melanoma Measures

Melanoma: percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within the 12 month period, into a recall system.

Melanoma: percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.

American Medical Association (4)

AMA/PCPI Oncology Physician Performance Measurement Set

Oncology: percentage of female patients aged 18 years and older with Stage I (T1b) through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period.

Oncology: percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Oncology: percentage of patients aged 18 through 80 years with American Joint Committee on Cancer (AJCC) Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period.

AMA/PCPI Prostate Cancer Performance Measurement Set

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very 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.

C

Centers for Medicare & Medicaid Services (1)

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.

F

French National Institute for Medical Research (INSERM) COMPAQ-HPST (1)

Quality and Content of Medical Records

New Multidisciplinary team (MDT) meeting in oncology: number of evaluated stays for the initial management of a first diagnosis of cancer.

N

NHS Scotland (107)

Cancer Quality Performance Indicators (QPIs)

Breast cancer: proportion of patients undergoing wide excision and/or an axillary sampling procedure for breast cancer as day case surgery.

Breast cancer: proportion of patients with breast cancer (invasive or ductal carcinoma in-situ) having breast conservation surgery with final radial excision margins of less than 1 mm.

Breast cancer: proportion of patients with breast cancer (invasive or in-situ) having breast conservation surgery who undergo re-excision or mastectomy following initial breast surgery.

Breast cancer: proportion of patients with breast cancer having conservation surgery who receive radiotherapy to the breast.

Breast cancer: proportion of patients with breast cancer under 30 years of age referred to a specialist clinic for genetic testing.

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

Breast cancer: proportion of patients with breast cancer who are enrolled in an interventional clinical trial or translational research.

Breast cancer: proportion of patients with breast cancer who die within 30 days of chemotherapy treatment.

Breast cancer: proportion of patients with breast cancer who undergo immediate breast reconstruction at the time of mastectomy.

Breast cancer: proportion of patients with invasive breast cancer for whom the HER2 status (as detected by immunohistochemistry [IHC] and/or fluorescence in-situ hybridization [FISH] analysis) is reported within 2 weeks of core biopsy.

Breast cancer: proportion of patients with invasive breast cancer who have a greater than or equal to 5% overall survival benefit of chemotherapy treatment predicted at 10 years that undergo adjuvant chemotherapy.

Breast cancer: proportion of patients with invasive breast cancer who undergo assessment of the axilla by ultrasound before surgery.

Breast cancer: proportion of patients with invasive breast cancer with suspicious morphology reported on ultrasound who undergo a fine-needle aspiration (FNA)/core biopsy of the axilla before surgery.

Breast cancer: proportion of patients with invasive or in-situ breast cancer who have a non-operative diagnosis (core biopsy/large volume biopsy).

Breast cancer: proportion of patients with triple negative breast cancer under 40 years of age referred to a specialist clinic for genetic testing.

Breast cancer: proportion of surgically treated patients with breast cancer less than 20 mm whole tumour size on histology (invasive plus in-situ disease) treated by breast conservation surgery.

Colorectal cancer: proportion of patients between 50 and 74 years of age at diagnosis with Dukes C, or high risk Dukes B, colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy.

Colorectal cancer: proportion of patients who undergo surgical resection for colorectal cancer who return to theatre to deal with complications related to the index procedure (within 30 days of surgery).

Colorectal cancer: proportion of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment.

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

Colorectal cancer: proportion of patients with colorectal cancer who die within 30 or 90 days of chemotherapy or radiotherapy treatment with curative intent.

Colorectal cancer: proportion of patients with colorectal cancer who die within 30 or 90 days of emergency or elective surgical resection.

Colorectal cancer: proportion of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon having anastomotic leak requiring intervention (radiological or surgical).

Colorectal cancer: proportion of patients with colorectal cancer who undergo curative surgical resection where greater than or equal to 12 lymph nodes are pathologically examined.

Colorectal cancer: proportion of patients with colorectal cancer who undergo elective surgical resection which involves stoma creation who are seen and have their stoma site marked pre-operatively by a nurse with expertise in stoma care.

Colorectal cancer: proportion of patients with colorectal cancer who undergo elective surgical resection who have the whole colon visualised by colonoscopy or CT colonography before surgery, unless the non-visualised segment of colon is to be removed.

Colorectal cancer: proportion of patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment.

Colorectal cancer: proportion of patients with rectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with total mesorectal excision [TME]) having anastomotic leak requiring intervention (radiological or surgical).

Colorectal cancer: proportion of patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neo-adjuvant radiotherapy in which the circumferential margin is clear of tumour.

Colorectal cancer: proportion of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy in which the circumferential margin is clear of tumour.

Colorectal cancer: proportion of patients with rectal cancer with threatened or involved circumferential resection margin (CRM) on pre-operative MRI who receive long course neo-adjuvant chemoradiotherapy.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing clinical examination of relevant draining lymph node basins as part of clinical staging.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing diagnostic excision biopsy who undergo a wide local excision.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing groin block dissection who have been referred to a lymphoedema service.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing partial biopsy who undergo a wide local excision.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing wide local excision within 84 days of their diagnostic excision biopsy.

Cutaneous melanoma: proportion of patients with cutaneous melanoma undergoing wide local excision within 84 days of their partial biopsy.

Cutaneous melanoma: proportion of patients with cutaneous melanoma who are discussed at a multidisciplinary team (MDT) meeting before definitive treatment.

Cutaneous melanoma: proportion of patients with cutaneous melanoma who have their diagnostic excision biopsy carried out by a skin cancer clinician.

Cutaneous melanoma: proportion of patients with cutaneous melanoma who undergo diagnostic excision biopsy where the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Cutaneous melanoma: proportion of patients with cutaneous melanoma who undergo sentinel node biopsy (SNB) where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Cutaneous melanoma: proportion of patients with stage III and IV cutaneous melanoma who undergo CT or positron emission tomography (PET) CT prior to completion lymphadenectomy.

Cutaneous melanoma: proportion of patients with unresectable stage III and IV cutaneous melanoma who undergo systemic anti-cancer therapy (SACT).

Cutaneous melanoma: proportion of patients with unresectable stage III or IV cutaneous melanoma who have their BRAF status checked.

Hepatopancreatobiliary (HPB) cancer: number of surgical resections for pancreatic, duodenal, or distal biliary tract cancer performed by each surgeon/centre in a given year.

Hepatopancreatobiliary (HPB) cancer: proportion of patients undergoing resection for pancreatic cancer who receive adjuvant chemotherapy.

Hepatopancreatobiliary (HPB) cancer: proportion of patients who undergo resection for pancreatic, duodenal, or distal biliary tract cancer.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with hepatocellular carcinoma (HCC) not undergoing treatment with curative intent (liver transplantation, resection or ablative therapies) who receive trans-arterial chemoembolisation (TACE) or approved systemic anti-cancer therapy (SACT).

Hepatopancreatobiliary (HPB) cancer: proportion of patients with hepatocellular carcinoma (HCC) undergoing disease specific treatment (liver transplant, resection, ablation, trans-arterial chemoembolisation [TACE] or systemic anti-cancer therapy [SACT]) who die within 30 days of definitive treatment.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with hepatocellular carcinoma (HCC) undergoing disease specific treatment with curative intent (liver transplant, resection, or ablation) who die within 90 days of definitive treatment.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with hepatocellular carcinoma (HCC) undergoing either CT or MRI and with full information recorded.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with hepatocellular carcinoma (HCC) who meet the current UK listing criteria for liver transplantation who are referred to the Scottish Liver Transplant Unit (SLTU).

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

Hepatopancreatobiliary (HPB) cancer: proportion of patients with pancreatic, duodenal or biliary tract cancer who undergo CT of the chest, abdomen and pelvis.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with pancreatic, duodenal or distal biliary tract cancer undergoing non-surgical treatment who have a histological or cytological diagnosis.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with pancreatic, duodenal, or distal biliary tract cancer undergoing surgical resection who die within 30 and 90 days.

Hepatopancreatobiliary (HPB) cancer: proportion of patients with pancreatic, duodenal, or distal biliary tract cancer who undergo pancreatoduodenectomy where greater than or equal to 15 lymph nodes are resected and pathologically examined.

Lung cancer: proportion of patients with a pathological diagnosis of non small cell lung cancer (NSCLC) who have a tumour subtype identified.

Lung cancer: proportion of patients with a pathological diagnosis of stage IIIB or IV non small cell lung cancer (NSCLC) who have molecular profiling undertaken.

Lung cancer: proportion of patients with limited stage (stage I to IIIB) small cell lung cancer (SCLC), performance status 0 or 1, who receive chemoradiotherapy (radiotherapy greater than or equal to 40Gy and concurrent or sequential platinum-based chemotherapy).

Lung cancer: proportion of patients with lung cancer not undergoing surgery who receive radiotherapy (greater than or equal to 54Gy) ± chemotherapy, or stereotactic ablative radiotherapy (SABR).

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

Lung cancer: proportion of patients with lung cancer who are enrolled in an interventional clinical trial or translational research.

Lung cancer: proportion of patients with lung cancer who have a pathological diagnosis (including following surgical resection).

Lung cancer: proportion of patients with lung cancer who receive active treatment who die within 30 days of treatment.

Lung cancer: proportion of patients with lung cancer who receive curative treatment (radical radiotherapy, radical chemoradiotherapy or surgical resection) who have a cytological/histological diagnosis prior to treatment.

Lung cancer: proportion of patients with lung cancer who receive treatment with curative intent (surgery, radical radiotherapy or chemoradiotherapy) who die within 90 days of treatment.

Lung cancer: proportion of patients with N2 disease who receive curative treatment (radical radiotherapy, radical chemoradiotherapy or surgical resection) who undergo contrast enhanced CT or contrast enhanced MRI prior to start of treatment.

Lung cancer: proportion of patients with non small cell lung cancer (NSCLC) not undergoing surgery who receive systemic anti-cancer therapy.

Lung cancer: proportion of patients with non small cell lung cancer (NSCLC) undergoing resection by lobectomy or pneumonectomy who have at least 1 node from at least 3 N2 stations sampled at time of resection or at previous mediastinoscopy.

Lung cancer: proportion of patients with non small cell lung cancer (NSCLC) who receive curative treatment (radical radiotherapy, radical chemoradiotherapy or surgical resection) who undergo PET CT prior to start of treatment.

Lung cancer: proportion of patients with non small cell lung cancer (NSCLC) who undergo surgical resection.

Lung cancer: proportion of patients with small cell lung cancer (SCLC) not undergoing treatment with curative intent who receive palliative chemotherapy.

Lung cancer: proportion of patients with small cell lung cancer (SCLC) who receive chemotherapy ± radiotherapy.

Lung cancer: proportion of patients with stage I lung cancer not undergoing surgery who receive stereotactic ablative radiotherapy (SABR).

Lung cancer: proportion of patients with stage I to II (T1aN0 to T2bN1, or T3N0) non small cell lung cancer (NSCLC) who undergo surgical resection.

Lung cancer: proportion of patients with stage IIIA non small cell lung cancer (NSCLC), with performance status 0-1, not undergoing surgery who receive chemoradiotherapy (radiotherapy greater than or equal to 54Gy and concurrent or sequential chemotherapy).

Lung cancer: proportion of patients with stage IIIB or IV non small cell lung cancer (NSCLC), with performance status 0 to 2 not undergoing surgery that are epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) positive who receive biological therapy.

Lymphoma: proportion of patients with Burkitt lymphoma and diffuse large B-cell lymphoma (DLBCL) undergoing treatment with curative intent who have MYC testing prior to treatment.

Lymphoma: proportion of patients with classical Hodgkin lymphoma (CHL) undergoing treatment with curative intent who undergo PET CT prior to treatment and within 2 weeks of radiology request.

Lymphoma: proportion of patients with classical Hodgkin lymphoma (CHL) undergoing treatment with curative intent who undergo PET CT prior to treatment.

Lymphoma: proportion of patients with diffuse large B cell lymphoma (DLBCL) who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT at end of chemotherapy treatment.

Lymphoma: proportion of patients with early stage (stage 1a or 2a) classical Hodgkin lymphoma (CHL) who receive combined modality treatment (chemotherapy and radiotherapy).

Lymphoma: proportion of patients with follicular lymphoma and diffuse large B cell lymphoma (DLBCL) who receive chemotherapy in combination with rituximab.

Lymphoma: proportion of patients with grade 3b follicular lymphoma who receive treatment with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) chemotherapy.

Lymphoma: proportion of patients with lymphoma undergoing rituximab based treatment who have hepatitis B, hepatitis C and HIV status checked prior to treatment.

Lymphoma: proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request.

Lymphoma: proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

Lymphoma: proportion of patients with lymphoma who are discussed at a multidisciplinary team (MDT) meeting within 6 weeks of diagnosis.

Lymphoma: proportion of patients with nodal, non-bulky stage 1a diffuse large B-cell lymphoma (DLBCL) who receive local radiotherapy, in combination with chemotherapy.

Lymphoma: proportion of patients with primary cutaneous lymphoma who are discussed at a specialist multidisciplinary team (MDT) meeting.

Prostate cancer: number of radical prostatectomy procedures performed by a surgeon over a 1 year period.

Prostate cancer: proportion of patients presenting with metastatic prostate cancer (TanyNanyM1) treated with immediate hormone therapy and docetaxel chemotherapy.

Prostate cancer: proportion of patients presenting with metastatic prostate cancer (TanyNanyM1) treated with immediate hormone therapy.

Prostate cancer: proportion of patients with high risk prostate cancer undergoing radical treatment who have MRI of the prostate and isotope bone scan (or alternative whole body MRI evaluation).

Prostate cancer: proportion of patients with intermediate risk prostate cancer undergoing radical treatment who have MRI of the prostate.

Prostate cancer: proportion of patients with metastatic prostate cancer (TanyNanyM1) discussed at the multidisciplinary team (MDT) meeting within 4 weeks of commencing treatment.

Prostate cancer: proportion of patients with non-metastatic prostate cancer (TanyNanyM0) discussed at the multidisciplinary team (MDT) meeting before definitive treatment.

Prostate cancer: proportion of patients with pathologically confirmed, organ confined (stage pT2) prostate cancer who undergo radical prostatectomy in which tumour is present at the margin (i.e., positive surgical margin).

Prostate cancer: proportion of patients with prostate adenocarcinoma who undergo prostate needle biopsy where the pathology report contains a full set of data items.

Prostate cancer: proportion of patients with prostate cancer under active surveillance who undergo multiparametric MRI within 6 months of diagnosis.

Prostate cancer: proportion of patients with prostate cancer under active surveillance who undergo trans-rectal ultrasound guided (TRUS) prostate re-biopsy within 14 months of diagnosis.

Prostate cancer: proportion of patients with prostate cancer undergoing radical prostatectomy with post surgical incontinence (greater than 0 pads per day measured using a validated tool) at 1 year (10 to 14 months) post radical prostatectomy.

Prostate cancer: proportion of patients with prostate cancer undergoing radical prostatectomy with post surgical incontinence (greater than 1 pad per day measured using a validated tool) at 1 year (10 to 14 months) post radical prostatectomy.

Prostate cancer: proportion of patients with prostate cancer who are enrolled in an interventional clinical trial or translational research.

Prostate cancer: proportion of patients with prostate cancer who die within 30 days of chemotherapy.

Prostate cancer: proportion of patients with prostate cancer who undergo trans-rectal ultrasound guided (TRUS) biopsy of the prostate where a minimum of 10 cores are received by pathology.

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