AQA Compendium of Approved Performance Measures Acute Otitis Externa/ Otitis Media with Effusion# Acute Otitis Externa Pain assessment Percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain Systematic antimicrobial therapy -- inappropriate use Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy Topical therapy Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations Otitis Media with Effusion Antihistamines or decongestants -- inappropriate use Percentage of patients aged 2 months through 12 years with a diagnosis of OME were not prescribed/recommended either antihistamines or decongestants Diagnostic evaluation -- Assessment of tympanic membrane mobility Percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry Hearing testing Percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion Systematic antimicrobials -- inappropriate use Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials Systematic steroids -- inappropriate use Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic steroids Anesthesiology/Critical Care# Prevention of Ventilator Associated Pneumonia –- Head Elevation Percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees) Prevention of Catheter Related Bloodstream Infections (CRBSI) – Catheter Insertion Protocol Percentage of patients who undergo CVC insertion for whom CVC insertion is defined to include use of: cap and mask and sterile gown and sterile gloves and a large sterile sheet and hand hygiene and 2% chlorhexidine for cutaneous antisepsis Perioperative Temperature Management Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 30 minutes immediately after anesthesia end time Asthma# Asthma Assessment Percentage of patients who were evaluated during at least on office visit during the reporting year for the frequency of daytime and nocturnal asthma symptoms Back Pain Recognition Programs and Measures* CM-1 Initial Visit The percentage of patients with a diagnosis of back pain who have medical record documentation of all of the following on the date of the initial visit to the physician. 1. Pain assessment 2. Functional status 3. Patient history, including notation of presence or absence of “red flags” 4. Assessment of prior treatment and response, and 5. Employment status CM-2 Physical Exam The percentage of patients with documentation of a physical examination on the date of the initial visit with the physician. CM-3 Mental Health Assessment The percentage of patients with a diagnosis of back pain for whom documentation of a mental health assessment is present in the medical record prior to intervention or when pain lasts more than six weeks. CM-4 Appropriate Imaging for Acute Back Pain The percentage of patients with a diagnosis of back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of “red flags” (overuse measure, lower performance is better). CM- 5 Repeat Imaging For Acute Back Pain The percentage of patients who received inappropriate repeat imaging studies in the absence of red flags or progressive symptoms (overuse measure, lower performance is better). CM-6 Advice for Normal Activities The percentage of patients with medical record documentation that a physician advised them to maintain or resume normal activities. CM-7 Advice Against Bed Rest The percentage of patients with medical record documentation that a physician advised them against bed rest lasting four days or longer. CM-8 Recommendation for Exercise The percentage of patients with back pain lasting more than 12 weeks, with documentation of physician advice for supervised exercise. CM-9 Appropriate Use of Epidural Steroid Injections The percentage of patients with back pain who have received an epidural steroid injection in the absence of radicular pain AND those patients with radicular pain who received an epidural steroid injection without image guidance (overuse measure, lower performance is better). CM-10 Surgical Timing The percentage of patients without documentation of red flags who had surgery within the first six weeks of back pain onset (overuse measure, lower performance is better). Note: This measure is applicable only for physicians who perform surgery. CM-11 Patient Reassessment The percentage of patients with documentation that the physician conducted reassessment of both of the following. o Pain, and o Functional status CM-12 Shared Decision Making The percentage of patients with whom a physician or other clinician reviewed the range of treatment options, including alternatives to surgery prior to surgery. To demonstrate shared decision making, there must be documentation in the patient record of a discussion between the physician and the patient that includes all of the following: o Treatment choices, including alternatives to surgery o Risks and benefits o Evidence of effectiveness Note: This measure is applicable only for physicians who perform surgery. S-1 Patient Education The physician provides patients with educational materials that review the natural history of the disease and treatment options, including alternatives to surgery, the risks and benefits and the evidence. Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. S-2 Post-Surgical Outcomes The physician has a system to examine post-surgical outcomes that includes the following. o Tracking specific complications of back surgery o Periodic analysis of surgical complications data and a plan for improving outcomes Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. This standard is applicable only for physicians who perform surgery. S-3 Evaluation of Patient Experience To demonstrate that the physician has mechanisms to evaluate patient experience there must be evidence of the following. o An ongoing system for obtaining feedback about patient experience with care o A process for analyzing the data and a plan for improving patient experience Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. Cardiac Surgery< 1. Anti-lipid treatment at discharge 2. Anti-platelet medications at discharge 3. Beta blockade at discharge 4. Deep sternal wound infection rate 5. Duration of prophylaxis for cardiac surgery patients 6. Participation in a systematic database for cardiac surgery 7. Post-operative renal insufficiency 8. Pre-operative beta blockade 9. Prolonged intubation 10. Risk-adjusted operative mortality for CABG 11. Selection of antibiotic administration for cardiac surgery patients 12. Surgical re-exploration 13. Stroke/ cerebrovascular accident 14. Timing of antibiotic administration for cardiac surgery patients 15. Use of internal mammary artery Cardiology# Coronary Artery Disease ACE Inhibitor or Angiotensin Receptor (ARB) Therapy Percentage of CAD patients with diabetes and/or LVSD who were prescribed ACE-I or ARB therapy. Antiplatelet Therapy Percentage of CAD patients who were prescribed antiplatelet therapy. Beta-Blocker Therapy- Prior Myocardial Infarction (MI) Percentage of CAD patients with prior MI who were prescribed beta-blocker therapy. Lipid Profile Percentage of CAD patients who received at least one lipid profile (or ALL component tests). Heart Failure ACE Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy Percentage of HF patients with LVSD who were prescribed ACE-I or ARB therapy. Beta-Blocker Therapy Percentage of HF patients with left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy. Left Ventricular Function (LVF) Assessment Percentage of HF patients with quantitative or qualitative results of LVF assessment recorded. Warfarin Therapy for Patients with Atrial Fibrillation (AF) Percentage of HF patients with paroxysmal or chronic AF who were prescribed warfarin therapy. Chronic Kidney Disease # Blood Pressure Management Percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure <130/80 mmHg OR blood pressure ≥130/80 mmHg with a documented plan of care. ACE Inhibitor (ACE) or Angiotensin Receptor Blocker (ARB) Therapy Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period. Laboratory Testing (Calcium, Phosphorus, PTH and Lipid Profile) Percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile. Plan of Care – Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA) Percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin < 13 g/dL OR patients whose hemoglobin is > 13 g/dL have a documented plan of care. Influenza Vaccination Percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February). Referral for AV Fistula Percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period. Chronic Wound Care# Patient Education Regarding Diabetic Foot Care Percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who received education regarding appropriate foot care and daily inspection of the feet within the 12 month period. Patient Education Regarding Long Term Compression Therapy Percentage of patients aged 18 years and older with a diagnosis of venous ulcer who received education regarding the need for long term compression therapy including interval replacement of compression stockings within the 12 month reporting period. Use of Compression System in Patients with Venous Ulcers Percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were prescribed compression therapy within the 12 month reporting period. Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique. Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers. Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings Clinical Endocrinology# General Population -- Screening or Therapy for Women Aged 65 Years and Older Percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months. Osteoporosis -- Counseling for Vitamin D and Calcium Intake and Exercise Percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months. Osteoporosis -- Pharmacologic Therapy Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months. Post-Fracture -- Communication with Physician Managing On-going Care Percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis. Post-Fracture -- Management Following Fracture Percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed. Dermatology # Melanoma Follow-Up Measures Percentage of patients with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) Patient was asked about new and changing moles AND (2) Patient received a complete physical skin examination AND (3) Patient was counseled to perform a monthly self skin examination. Melanoma Coordination of Care Percentage of patients seen with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis. Melanoma Continuity of Care – Recall System Percentage of patients with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period. Overutilization of Imaging Studies in Stage 0-1A Melanoma Percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered. Emergency Medicine# Aspirin at Arrival for AMI Percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay. Assessment of Mental Status for Community-Acquired Bacterial Pneumonia Percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed. Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia Percentage of patients aged 18 years and older with the diagnosis of community-acquired bacteria pneumonia with oxygen saturation assessed. Care Coordination for PCI for AMI Percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic ECG. Electrocardiogram Performed for Non-Traumatic Chest Pain Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had an ECG performed. Electrocardiogram Performed for Syncope Percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had an ECG performed. Empiric Antibiotic for Community-Acquired Bacterial Pneumonia Percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed. Fibrinolytic Therapy Ordered Within 20 Minutes of ECG Performed for AMI Percentage of patients (regardless of age) with an emergency department diagnosis of acute myocardial infarction who received thrombolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the ECG. Vital Signs for Community-Acquired Bacterial Pneumonia Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs recorded and reviewed. Endoscopy & Polyp Surveillance# Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Percentage of patients aged 50 years and older receiving a screening colonoscopy without Biopsy or Polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their Colonoscopy report. Comprehensive Colonoscopy Documentation Percentage of final colonoscopy reports for patients aged 18 years and older that include documentation of all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowl prep; complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; and recommendations for follow-up. Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate Use Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report. End Stage Renal Disease# Influenza Vaccination Percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the 12 month reporting period. Plan of Care for Anemia Percentage of calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis have a Hgb ≥ 11 AND patients have a Hgb < 11 with a documented plan of care. Plan of Care for Inadequate Hemodialysis Percentage of calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis have a Kt/V≥1.2 AND patients have a Kt/V<1.2 with a documented plan of care. Plan of Care for Inadequate Peritoneal Dialysis Percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V>1.7 AND patients who have a Kt/V<1.7 with a documented plan of care at least twice during the 12 month reporting period. Vascular Access - Patients Receiving Hemodialysis Percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula AND patients who are referred for an AV fistula/permanent vascular access at least once during the 12 month reporting period. Vascular Access - Patients Receiving Dialysis with a Permanent Catheter Percentage of patients aged 18 years and older with a diagnosis of ESRD with a permanent catheter after 90 days on dialysis who are referred for evaluation for permanent vascular access at least once during the 12 month reporting period. Eye Care# Age-Related Macular Degeneration (AMD): Antioxidant Supplement Prescribed/ Recommended Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration with at least one antioxidant vitamin or mineral supplement prescribed/recommended within 12 months. Age-Related Macular Degeneration (AMD): Dilated Macular Examination Percentage of patients aged 50 years and older with a diagnosis of age related macular degeneration who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months. Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery. Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery. Cataracts: Postoperative Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence. Cataracts: Comprehensive Pre-operative Assessment for Cataract Surgery with Intraocular (IOL) Placement Percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam, 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery. Primary Open-Angle Glaucoma: Optic Nerve Evaluation Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months. Primary Open-Angle Glaucoma: Counseling on Glaucoma Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence. Primary Open-Angle Glaucoma: Reduction of Intraocular Pressure by 15% or Documentation of a Plan of Care Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months. Diabetic Retinopathy: Communication with the Physician Managing the On-going Diabetes Care Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months. Gastroesophageal Reflux Disease (GERD) # Assessment for Alarm Symptoms Percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding. Barium Swallow -- Inappropriate Use Percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a Barium swallow test ordered. Biopsy for Barrett's Esophagus Percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed. Chronic Medication Therapy – Assessment of GERD Symptoms All patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months. Upper Endoscopy for Patients with Alarm Symptoms Percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed. General Thoracic Surgery< Participation in a Systematic Database for Thoracic Surgery The physician participates in a multi-center, data collection and feedback program that provides benchmarking relative to peers and uses process and outcomes measures. Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection Percentage of all surgical patients undergoing staging or treatment procedures for lung or esophageal cancer that have clinical TNM staging provided. Pulmonary Function Tests Before Major Anatomic Lung Resection (pneumonectomy, lobectomy) Percentage of thoracic surgical patients, >/= 18 years of age who underwent at least one pulmonary function test no more than 12 months prior to a major lung resection. Recording of Performance Status (Zubrod, Karnofsky, WHO or ECOG Performance Status) Prior to Lung or Esophageal Cancer Resection Percentage of patients undergoing resection of a lung or esophageal cancer who had the performance status recorded within two weeks of the surgery date. Screening for Smoking Status – Surgical Procedures Percentage of surgical patients >/=18 years of age who were queried by the surgeon or his/her staff about past and current smoking habits and whose responses were entered in the patient’s medical record. Geriatrics # Care Coordination Medication Reconciliation Percentage of patients aged 65 years and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented. End of life care Advanced Care Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation* in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. * Definition: Documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. This documentation in the medical record could also include as appropriate that the patient's cultural and/or spiritual beliefs preclude a discussion of advance care planning as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patient relationship. Falls Plan of Care Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months Risk Assessment Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months Screening for Fall Risk Percentage of patients aged 65 years and older who were screened for fall risk (2 or more falls in the past year or any fall with injury in the past year) at least once within 12 months Urinary Incontinence Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months. Characterization of Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months. Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months. Hematology # Chronic Lymphocytic Leukemia – Baseline flow cytometry Percentage of patients aged 18 years and older with a diagnosis of CLL who had baseline flow cytometry studies performed. MDS and Acute Leukemias – Baseline cytogenetic testing performed on bone marrow Percentage of patients aged 18 years and older with a diagnosis of MDS or an acute leukemia who had baseline cytogenetic testing performed on bone marrow. MDS – Documentation of iron stores in patients receiving erythropoietin therapy Percentage of patients aged 18 years and older with a diagnosis of MDS who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy. Multiple Myeloma – Treatment with bisphosphonates Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period. Hepatitis C# Antiviral Treatment Prescribed Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed peginterferon and ribavirin therapy within the 12 month reporting period. Counseling Regarding Use of Alcohol Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received counseling regarding use of alcohol at least once within the 12 month reporting period. Counseling Regarding Use of Contraception Prior to Antiviral Therapy Percentage of female patients aged 18 to 44 years and all men aged 18 years and older with a diagnosis chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of antiviral treatment. Consideration for Antiviral Therapy – no longer part of AMA PCPI set Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were considered for peginterferon and ribavirin therapy within the 12 month reporting period. HCV Genotype Testing Prior to Treatment Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom HCV genotype testing was performed prior to initiation of treatment. HCV RNA Testing at Week 12 of Therapy Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom quantitative HCV RNA testing was performed at 12 weeks of treatment. Hepatitis A Vaccination – paired with measure below Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A. Hepatitis B Vaccination – paired with measure above Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B. Hepatitis C RNA Testing Before Initiating Treatment Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom a quantitative HCV RNA testing was performed within 6 months prior to initiation of treatment. Testing for Chronic Hepatitis C: Confirmation of Hepatitis C Viremia Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who had HCV RNA testing ordered or performed. Major Depressive Disorder# Diagnostic Evaluation Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who met the DSM-IVTM criteria during the visit in which the new diagnosis or recurrent episode was identified during the measurement period. Suicide Risk Assessment Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) who had a suicide risk assessment completed at each visit during the measurement period. Measures for Surgery# Discontinuation of Prophylactic Antibiotics (Cardiac Procedures) Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time. Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time. Selection of Prophylactic Antibiotic – First or Second Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis. Timing of Prophylatic Antibiotics – Administering Physician Percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour(if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required). Timing of Prophylatic Antibiotics – Ordering Physician Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics who have an order for an antibiotic to be given within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required). Venous Thromboembolism (VTE) Prophylaxis Percentage of patients undergoing procedures for which VTE prophylaxis is indicated in all patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time. Neurology# Anticoagulant Therapy Prescribed for Atrial Fibrillation Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge. Consideration of Rehabilitation Services Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented Discharged on Antiplatelet Therapy Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge. Screening for Dysphagia Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth. Tissue Plasminogen Activator (t-PA) Considered Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for t-PA administration. Non-Physician Measures** Elder Maltreatment Screen and Follow-up Plan Percentage of patients age 65 years and older with documentation of a screen for elder maltreatment and documented follow-up plan. Functional Outcome Assessment in Chiropractic Care Percentage of patients age 18 years and older with documentation of a current functional outcome assessment using a standardized tool AND documentation of a treatment plan based on identified deficiencies. Pain Assessment Prior to Initiation to Patient Therapy Percentage of patients aged 18 years and older with documentation of a pain assessment (if pain is present, including location, intensity and description) through discussion with the patient or through use of a standardized tool on each initial evaluation prior to initiation of therapy. Patient Co-development of the Treatment Plan/Plan of Care Percentage of patients aged 18 years and older identified as having actively participated in the development of the treatment plan/plan of care. Appropriate documentation includes signature of the practitioner and either co-signature of the patient or documented verbal agreement obtained from the patient or, when necessary, an authorized representative. Screening for Clinical Depression Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool. Screening for Cognitive Impairment Percentage of patients aged 65 years and older that have documentation of results of a screening for cognitive impairment using a standardized tool. Universal Documentation and Verification of Current Medications in the Medical Record Percentage of patients aged 18 years and older with written provider documentation that current medications with dosages (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) were verified with the patient or authorized representative. Universal Influenza Vaccine Screening and Counseling Percentage of patients aged 50 years and older that were screened and counseled about the influenza vaccine during the months of January, February, March, October, November and December. Universal Weight Screening and Follow-up Percentage of patients aged 65 years and older with a calculated BMI in the past six months documented in the medical record AND if the most recent BMI is ≥ 30 or < 22, a follow-up plan is documented. Nuclear Medicine: Radionuclide Bone Imaging# Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (eg, x-ray, MRI, CT,) that were performed Oncology# Cancer Stage Documented Percentage of patients with a diagnosis of breast, colon, or rectal cancer seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period. Chemotherapy for Stage IIIA-Stage IIIC colon cancer patients Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are prescribed or who have received adjuvant chemotherapy within the 12 month reporting period. Hormonal Therapy for Stage IC-IIIC, ER/PR Positive Breast Cancer Percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) within the 12 month reporting period. Normal Tissue Dose Constraints Specified Percentage of patients with a diagnosis of cancer receiving 3D conformal radiation therapy with documentation in medical record that normal tissue dose constraints were established within five treatment days for a minimum of one tissue. Pain Intensity Quantified -Medical Oncology and Radiation Oncology Percentage of visits for patients with a diagnosis of cancer currently receiving intravenous chemotherapy or radiation therapy in which pain intensity is quantified. Plan of Care for Pain Percentage of visits for patients with a diagnosis of cancer currently receiving intravenous chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain. Plan for Chemotherapy Documented Percentage of patients with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug(s) prescribed, dose, and duration) is documented prior to the initiation of a new treatment regimen. Treatment Summary Communication – Radiation Oncology Percentage of patients with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary* report in the chart that was communicated to the physician(s) providing continuing care within one month of completing treatment. *Treatment Summary definition - a report that includes mention of all of the following components: 1) dose delivered; 2) relevant assessment of tolerance to and progress towards the treatment goals; and 3) subsequent care plans. Orthopedic Surgery# Osteoporosis – Counseling for Vitamin D and Calcium Intake and Exercise Percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months. Post-Fracture – Communication with the Physician Managing On-going Care Post Fracture Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis. Osteoarthritis# Assessment for Use of Anti-inflammatory or Analgesic Over-the-Counter (OTC) Medications Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA with an assessment for use of anti-inflammatory or analgesic OTC medications. Pain and Function Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis with assessment for function and pain. Palliative Care Measure*,# Advance Care Planning Percentage of patients with advanced chronic or serious life threatening illness who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan in the medical record. Dyspnea Screening and Dyspnea Management Percentage of patients with advanced chronic or serious life threatening illnesses that are screened for dyspnea. For those that are diagnosed with moderate or severe dyspnea, a documented plan of care to manage dyspnea exists. Pathology# Breast Cancer Resection Pathology Reporting Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade. Colorectal Cancer Resection Pathology Reporting Measure: Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade. Podiatry## Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities during one or more office visits within 12 months. Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of Footwear Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing during one or more office visits within 12 months. Primary Care (Ambulatory Care Starter Set) Asthma Asthma: Pharmacologic Therapy# Percentage of all individuals with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment. Use of Appropriate Medications for People w/ Asthma* Percentage of individuals who were identified as having persistent asthma during the year prior to the measurement year and who were appropriately prescribed asthma medications (e.g. inhaled corticosteroids) during the measurement year. Coronary Artery Disease Beta-Blocker Therapy – Post MI* Percentage patients hospitalized with AMI who received persistent beta-blocker treatment (6 months after discharge). Beta-Blocker Treatment after Heart Attack* Percentage of patients hospitalized with acute myocardial infarction (AMI) who received an ambulatory prescription for beta-blocker therapy (within 7 days discharge). Drug Therapy for Lowering LDL Cholesterol# Percentage of patients with CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines). Depression Antidepressant Medication Management* Acute Phase: Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug during the entire 84-day (12-week) Acute Treatment Phase. Antidepressant Medication Management* Continuation Phase: Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug for at least 180 days (6 months). Diabetes Eye Exam* Percentage of patients who received a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) during the reporting year or during the prior year if patient is at low risk for retinopathy. o A patient is considered low risk if all three of the following criteria are met: (1) the patient is not taking insulin; (2) has an A1C less than 8.0%; and (3) has no evidence of retinopathy in the prior year. HbA1C Management* Percentage of patients with diabetes with one or more A1C test(s) conducted during the measurement year. HbA1C Management Control* Percentage of patients with diabetes with most recent A1C level greater than 9.0% (poor control). LDL Cholesterol Level* Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dL or less than 130 mg/dL. Lipid Measurement* Percentage of patients with diabetes with at least one Low Density Lipoprotein cholesterol (LDL-C) test (or ALL component tests). Blood Pressure Management# Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mm Hg. Heart Failure ACE Inhibitor /ARB Therapy# Percentage of patients with heart failure who also have LVSD who were prescribed ACE inhibitor or ARB therapy. LVF Assessment# Percentage of patients with heart failure with quantitative or qualitative results of LVF assessment recorded. Prenatal Care Anti-D Immune Globulin# Percentage of D (Rh) negative, unsensitized patients who received anti-D immune globulin at 26-30 weeks gestation. Screening for Human Immunodeficiency Virus# Percentage of patients who were screened for HIV infection during the first or second prenatal visit. Preventative Measures Advising Smokers to Quit* Percentage of patients who received advice to quit smoking Breast Cancer Screening* Percentage of women who had a mammogram during the measurement year or year prior to the measurement year. Cervical Cancer Screening* Percentage of women who had one or more Pap tests during the measurement year or the two prior years. Colorectal Cancer Screening* The percentage of adults who had an appropriate screening for colorectal cancer. o One or more of the following: 1. FOBT – during measurement year; 2. Flexible sigmoidoscopy – during the measurement year or the four years prior to the measurement year; 3. DCBE – during the measurement year or the four years prior; 4. Colonoscopy – during the measurement or nine years prior. Influenza Vaccination* Percentage of patients [50-64] who received an influenza vaccination. Pneumonia Vaccination* Percentage of patients who ever received a pneumococcal vaccine. Tobacco Use # Percentage of patients who were queried about tobacco use one or more times during the twoyear measurement period. Quality Measures Addressing Overuse or Misuse Appropriate Testing for Children with Pharyngitis* Percentage of patients who were diagnosed with pharyngitis, prescribed an antibiotic and who received a group A streptococcus test for the episode. Appropriate Treatment for Children with Upper Respiratory Infection (URI)* Percentage of patients who were given a diagnosis of URI and were not dispensed an antibiotic prescription on or 3 days after the episode date. Prostate Cancer# Initial Evaluation Percentage of patients with prostate cancer receiving interstitial prostate brachytherapy, or external beam radiotherapy to the prostate, or radical prostatectomy, or cryotherapy with documented evaluation of prostate-specific antigen (PSA), and primary tumor (T) stage, and Gleason score prior to initiation of treatment. Avoidance of Overuse Measure – Bone Scan for Staging Low-Risk Patients Percentage of patients 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. Treatment Options for Patients with Clinically Localized Disease Percentage of patients with clinically localized prostate cancer receiving interstitial prostate brachytherapy, or external beam radiotherapy to the prostate, or radical prostatectomy, or cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy , AND radical prostatectomy. Adjuvant Hormonal Therapy for High-Risk Patients Percentage of patients with a diagnosis of prostate cancer, at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist). Three-Dimensional Radiotherapy Percentage of patients with prostate cancer receiving external beam radiotherapy to the prostate only who receive 3D-CRT or IMRT. Radiology# Communication of Suspicious Findings from the Diagnostic Mammogram to the Practice Managing Ongoing Care Percentage of patients undergoing diagnostic mammograms that are classified as “suspicious” or “highly suggestive of malignancy” with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient’s on-going care within 3 business days of exam interpretation. Communication of Suspicious Findings from the Diagnostic Mammogram to the Patient Percentage of patients undergoing diagnostic mammograms that are classified as “suspicious” or “highly suggestive of malignancy” with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation. CT or MRI Reports Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage or at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction. CT Radiation Dose Reduction Percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure. Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke OR intracranial hemorrhage who received DVT prophylaxis by end of hospital day two. Exposure Time Reported for Procedures Using Fluoroscopy Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time. Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening Percentage of final reports for screening mammograms that are classified as “probably benign.” Mammography Assessment Category Data Collection Percentage of patients undergoing screening mammograms whose assessment category [eg, Mammography Quality Standards Act (MQSA), Breast Imaging Reporting and Data System (BI-RADS®), or FDA approved equivalent categories] is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate. Reminder System for Mammograms Percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system* with a target due date for the next mammogram. Stenosis Measurement in Carotid Imaging Reports Percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement. Rheumatoid Arthritis# Tuberculosis Screening Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying antirheumatic drug (DMARD). Periodic Assessment of Disease Activity Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity at least once within 12 months. Functional Status Assessment Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within twelve months. Assessment and Classification of Disease Prognosis Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months. Glucocorticoid Management Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months Rheumatology# General Population – Screening or Therapy for Women Aged 65 Years and Older Percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months Osteoporosis – Counseling for Vitamin D and Calcium Intake and Exercise Percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months Osteoporosis – Pharmacologic Therapy Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months Post-Fracture – Communication with Physician Managing On-going Care Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis Post-Fracture – Management Following Fracture Percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed Structural Measures NCQA PPC Stand Alone Measures* Electronic System for Clinical Data Percentage of patients with a physician visit, where a clinical data system was used to manage the care of the patient. Prescribing Decision Support – Safety Percentage of patients with a physician visit for whom an e-prescribing system was used, where the practice uses alerts and information, during the reporting period. Preventive Care Reminders at Point of Care Percentage of patients with a physician visit, where a guideline-based decision support system was used when seeing the patient, during the reporting period. Test and Referral Tracking and Follow Up Percentage of patients with a physician visit, where a test tracking and follow up system was used. Use of Electronic Prescribing Percentage of patients with a physician visit for whom an e-prescribing system was used during the reporting period. Use of System for Population Management Percentage of patients with a physician visit, where a registry or reminder system for population management was used. Quality Insights of Pennsylvania Structural Measures** Adoption of Health Information Technology Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted a qualified electronic medical record (EMR). For the purpose of this measure, qualified EMR can either be a Certification Commission for Healthcare Information Technology (CCHIT) certified EMR or, if not CCHIT certified, the system must be capable of all of the following: o Generating a medication list o Generating a problem list o Entering laboratory tests as discrete searchable data elements Adoption of Medication e-Prescribing Documents whether provider has adopted a qualified e-Prescribing system and the extent of use in the ambulatory setting. To qualify this system must be capable of ALL of the following: o Generating a medication list o Selecting medications, printing prescriptions or transmitting them (if allowed by state law and within provider’s scope of practice), and conducting safety checks Substance Use Disorders# Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence within the 12-month period. Counseling regarding Psychosocial and Pharmacologic Treatment Options for Opioid addiction Percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial and pharmacologic treatment options for opioid addiction within the 12-month reporting period. Screening for Depression Among Patients with Substance Abuse or Dependence Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period. Unhealthy Alcohol Use# Unhealthy Alcohol Use: Screening Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method * This performance measure was developed by and is owned by and the National Committee for Quality Assurance ("NCQA"). # Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for Performance Improvement http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinicalquality/physician-consortium-performance-improvement/pcpi-measures.shtml ## This performance measure was developed by and is owned by and the American Podiatric Medical Association. ** This performance measure was developed by and is owned by Quality Insights of Pennsylvania. < These performance measures were developed by the Society of Thoracic Surgeons.