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Ambulatory Care

Follow-up After Emergency Department Visits for Asthma

This process measure seeks to capture follow up after asthma-related emergency department (ED) visits for children with asthma after discharge from the ED, as recommended by the NHLBI 2007 guidelines. This measure assesses the percentage of asthma-related ED visits for children ages 3-21 with a follow-up visit with a primary care clinician or an asthma subspecialist within 14 days of discharge from the ED, within the reporting year, for patients who are enrolled in the health plan for two consecutive months following the ED visit. 

CBE ID
3668

Optimal End Stage Renal Disease (ESRD) Starts

Information From 2015 Submission

Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis (peritoneal dialysis or home hemodialysis), or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.

CBE ID
2594

Preventive Care and Screening: Influenza Immunization

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

CBE ID
0041e

Unplanned Anterior Vitrectomy

CMS Measures Inventory Tool (CMIT) ID
00735-01-C-ASCQR
Steward Organization Group
ASC Quality Collaboration
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Ambulatory Surgical Center Quality Reporting
CMS Program History
  • Measure finalized in rulemaking in 2017.
  • Measure implemented in Ambulatory Surgical Center Quality Reporting Program (ASCQRP) in 2021. 
Description

This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

Numerator

All cataract surgery patients who had an unplanned anterior vitrectomy.

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

All cataract surgery patients.

Denominator Exclusions

None.

Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Ambulatory Care
CBE Endorsement Status
Not Endorsed
CBE Endorsement History

N/A

About this Analysis (Measure Score by PY)

Impact Summary: This measure aligns with the Ambulatory Surgical Center Quality Reporting (ASCQR) objectives by enabling both facilities and consumers to evaluate and compare the quality of care for cataract surgery provided in the ambulatory surgical center (ASC) setting and ensuring that care processes support the best possible patient outcomes. Specifically, the measure assesses the percentage of cataract surgery patients who experience an unplanned anterior vitrectomy (a lower score indicates better quality of care).

Figure 1 shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. Table 1 shows that if all entities performed at least at the average, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, a small increase that may potentially leading to better health outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:

  • Hospitals_02_2026.zip (which contains data from 2024)
  • Hospitals_08_2025.zip (which contains data from 2023)
  • Hospitals_07_2024.zip (which contains data from 2022)
  • Hospitals_10_2023.zip (which contains data from 2021)
  • Hospitals_07_2022.zip (which contains data from 2020)

Battelle analyzed all numeric values in column “ASC-14 Rating*” from the corresponding ASC_Facility.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: This figure shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores across deciles for the most recent year of data available.

Table 1 (Score Distro)

 Table 1. Importance (Decile by Measure Score, 2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average Score (Standard Deviation)0.47 (3.52)00.010.080.130.190.260.340.450.632.62
Entities 1,640164164164164164164164164164164
Interpretation (Score Distro)

Table 1 Interpretation: Nearly 20% of the entities have a score at or near 0%, and about 80% have a score less than 0.5%. If the average performance of Decile 3 (0.8%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, potentially leading to better health outcomes.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)