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#
CAD
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)
HF
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
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
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
endoscopy 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#
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 male patients aged 18 years and older
with a diagnosis of chronic hepatitis C who are receiving treatment who were counseled
regarding contraception prior to the initiation of treatment
Combination Antiviral Therapy
 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
Consideration for Antiviral Therapy
 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
Hepatitis A Vaccination
 Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
recommended to receive or have received hepatitis A vaccination, or who have documented
immunity
Hepatitis B Vaccination
 Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
recommended to receive or have received hepatitis B vaccination, or who have documented
immunity
HCV Genotype Testing Prior to Therapy
 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
Initial Hepatitis C virus (HCV) ribonucleic acid (RNA) testing
 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 Prophylatic 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**
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
Orthopaedic 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
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#
Carotid Imaging Reports
 Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA
whose final reports of the carotid imaging studies performed, with characterization of an
internal carotid stenosis in the 30-99% range include reference to measurements of distal
internal carotid diameter as the denominator for stenosis measurement
CT or MRI Reports
 Percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA
or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at
the hospital whose final report of the CT or MRI includes documentation of the presence or
absence of each of the following: hemorrhage and mass lesion and acute infarction’
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
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
Breast Imaging Reporting and Data System (BI-RADS®) data collection
 Percentage of patients undergoing screening mammograms whose BI-RADS® assessment
category is entered into an internal database that will, at a minimum, allow analysis of
abnormal interpretation (recall) rate
Inappropriate use of Breast Imaging Reporting and Data System (BI-RADS®) category 3 in
Mammography Screening
 Percentage of final reports for screening mammograms that are classified as BI-RADS®
category 3
Communication of Suspicious Findings from the Diagnostic Mammogram to the Practice
Managing Ongoing Care
 Percentage of patients undergoing diagnostic mammograms that receive a final BI-RADS®
assessment category of 4 or 5 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 receive a final BI-RADS®
assessment category of 4 or 5 with documentation of direct communication of findings from
the diagnostic mammogram to the patient within 5 business days of exam interpretation
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
CT radiation dose reduction
 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
Exposure time reported for procedures using fluoroscopy
 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
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
* 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
## 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.