NQF

Measure Applications Partnership
Clinician Workgroup Discussion Guide

In-person meeting dates: December 15-16, 2014
National Quality Forum Conference Center
1030 15th Street NW, 9th Floor, Washington, DC 20005

Meeting Objectives

Agenda

Day 1  


8:45 am   Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach
Mark McClellan, MD, PhD, Workgroup Chair
Reva Winkler, MD, MPH, Senior Director, NQF

9:00 am   Follow-up from October web meeting
Dr. McClellan

9:30 am   Discussion of eMeasures and cost measures
CMS

9:50 am   Overview of Pre-Rulemaking Approach
Dr. Winkler

10:00 am   Consent Calendar 1: Care Coordination
Four process measures are under consideration for PQRS based programs; three are also under consideration for the EHR incentive program (“Meaningful Use”). All measures are still in development. For 2015 PQRS has finalized only two process measures and one outcome measure in the priority area of care coordination.
Lead discussant(s): Rachel Grob, Robert Krughoff
  1. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 4
    • Preliminary analysis summary: Care coordination measure specific for EHRs that uses Clinical Document Architecture (CDA) that specifies how critical data elements should be encoded for exchange and interoperability. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Care coodination measure of ED provider attempting to contact patient's primary care provider or specialist after a patient is seen with with asthma or chest pain. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Care coordination measure of follow-up within 72 hours after an ED visit for asthma or chest pain. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Communication and shared decision-making with patients and families for interventional oncology procedures (MUC ID: X3735)
    • Description: Percentage of patients who have undergone an interventional oncology ablation or catheter-directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was discussed with the patient and/or family member (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Care coordination and patient-centered measure. A patient-reported outcome measure to assess the patient or family's perspective of the discussion would be of higher value than a documentation measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


10:15 am   Consent Calendar 2: Medication Management
Seven process measures are under consideration for PQRS based programs for medication management including four process measures in the new topic area of chronic opioid therpy (COT). Three process measures are under consideration for PQRS based programs (one is also for EHR Incentive) for monitoring warfarin use. For PQRS 2015 there are four process measures for medication management including an intermediate outcome measure for warfarin use.
Lead discussant(s): Amy Mullins, Janis Orlowski
  1. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)

  2. Consideration of Non-Pharmacologic Interventions (MUC ID: X3776)

  3. Documentation of Signed Opioid Treatment Agreement (MUC ID: X3777)

  4. Chronic Opioid Therapy Follow-up Evaluation (MUC ID: X3775)

  5. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Patient safety process eMeasure applied to all patients on warfarin. NQF has endorsed this measure but has not considered the eMeasure. Related to PQRS #380 about the time an atrial fibriallation patient's INR is in the correct range (intermediate outcome). This measure under consideration captures the broadest population of all patients taking warfarin regardless of diagnosis. In view of multiple measures for warfarin management and to promote harmonization and parsimony suggest focusing on a process (monitoring INR) and an intermediate outcome (time in therapeutic range) measure for all patients taking warfarin. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Related to PQRS measure #380 (intermediate outcome) addressing warfarin use in patients with atrial fibrillation. This measure is duplicative and not harmonized with NQF-endorsed measure under consideration E0555 that applies to a broader population of all patients taking warfarin. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  8. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


10:45 am   Consent calendar 3: Emergency care
Three new process measures are under consideration for PQRS programs; two are also for the EHR Incentive program. All measures are still in development. There are only two process measures for emergency care finalized for PQRS 2015. Three of the new measures address appropriate use of imaging and lab tests in the ED.
Lead discussant(s): Beth Averbeck, Mark Metersky
  1. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)

  2. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)

  3. Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding (MUC ID: X3780)

  4. Imaging in adult ED patients with minor head injury (MUC ID: X3764)
    • Description: Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) <=15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Imaging in pediatric ED patients aged 2 through 17 years with minor head injury (MUC ID: X3778)
    • Description: Percent of pediatric patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) of 14 or 15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines (PECARN) prior to imaging (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


11:00 am   Consent calendar 4: Imaging
Six new measures are under consideration for PQRS based programs; all are still in development. Four measures address appropriate use of imaging and one is an adverse outcome measure. For 2015 PQRS has twelve finalized measures for imaging but none in the areas addressed by the new measures.
Lead discussant(s): David Hopkins, Jay Schuur
  1. Appropriate follow-up imaging for incidental abdominal lesions (MUC ID: X3759)

  2. Appropriate follow-up imaging for incidental thyroid nodules in patients (MUC ID: X3763)

  3. Appropriate follow-up imaging for non-traumatic knee pain (MUC ID: X3802)

  4. Appropriate use of imaging for non-traumatic shoulder pain (MUC ID: X3803)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value appropriate use of imaging measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Extravasation of contrast following contrast-enhanced computed tomography (CT) (MUC ID: X3523)

  6. Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy (MUC ID: X3781)

11:15 am   Consent calendar 5: Population Health 1
Lead discussant(s): Diane Padden, Peter Briss
  1. Cervical Cancer Screening (MUC ID: E0032)
    • Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21-64 who had cervical cytology performed every 3 years. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure at the plan and system level.This is a population measure important to consumers is and consistent with the most recent guidelines. Important for dual eligibles. Conditional on successful testing for reliability and validity at the clinician level. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Blood Pressure Screening by age 18 (MUC ID: E1553)
    • Description: The percentage of adolescents who turn 18 years of age in the measurement year who had a blood pressure screening with results. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: "CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented". (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  3. Blood Pressure Screening by age 18 (MUC ID: E1553)

  4. Breast Cancer Screening (MUC ID: X3797)

  5. Unnecessary Screening Colonoscopy in Older Adults (MUC ID: X3769)

  6. Appropriate age for colorectal cancer screening (MUC ID: X3758)

11:30 am   Consent calendar 6: Population Health (children and adolescents)
There is one measure under consideration for the PQRS based programs and three for the EHR Incentive program. For PQRS 2015 there are six population screening measures for children and adolescents but these are new areas.
Lead discussant(s): Terry Adirim, Cynthia Pellegrini
  1. Amblyopia Screening in Children (MUC ID: X3817)

  2. Amblyopia Screening in Children (MUC ID: X3817)

  3. Risky Behavior Assessment or Counseling by Age 13 Years (MUC ID: E1406)
    • Description: The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 13 years. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Suggest broadening the age range and combing this measure with E1507 Risky Behavior Assessment or Counseling by age 18 years. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Risky Behavior Assessment or Counseling by Age 18 Years (MUC ID: E1507)
    • Description: The percentage of children with documentation of a risk assessment or counseling for risky behaviors by 18 years of age. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Suggest broadening the age range and combining with measure E1406 for parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


11:45 am   Consent calendar 7: Population Health 3
There are five new process eMeasures under consideration for the PQRS based programs; four are also under consideration for the EHR Incentive program. All eMeasures are in development. There is only one measure for Hepatitis C screening finalized for PQRS in 2015.
Lead discussant(s): James Pacala, Marci Nielsen
  1. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)
    • Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received a one-time screening for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: A?ligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)

  3. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users (MUC ID: X3513)
    • Description: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Measure is already in PQRS and is a high priority quality issue for dual eligibles. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)

  5. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)
    • Description: Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. HIV: Ever screened for HIV (MUC ID: X3299)

  7. HIV: Ever screened for HIV (MUC ID: X3299)

  8. HIV Screening of STI patients (MUC ID: X3300)

  9. HIV Screening of STI patients (MUC ID: X3300)

12:00 pm   Consent calendar 8: Population Health 4
Three eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program including one composite measure; all are in development. There is one measure for alcohol use screening finalized for PQRS 2015.
Lead discussant(s): Amy Mullins, Luther Clark
  1. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)

  2. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)

  3. Substance Use Screening and Intervention Composite (MUC ID: X3475)

  4. Substance Use Screening and Intervention Composite (MUC ID: X3475)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 7
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 6
    • Preliminary analysis summary: An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009. This measure is also duplicative of composite MUC X3475 as alcohol screening is one of the components. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  6. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 3
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


1:00 pm   Consent calendar 9: Mental Health and Substance Use
Three eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program; all are in development. The new measures include an outcome measure and a medication safety measure. There are no measures in these areas finalized for PQRS in 2015.
Lead discussant(s): Amy Moyer, Amy Compton-Phillips
  1. ADHD: Symptom Reduction in Follow-up Period (MUC ID: X3280)

  2. ADHD: Symptom Reduction in Follow-up Period (MUC ID: X3280)
    • Description: Percentage of children aged 4 through 18 years, with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), who demonstrated a 25% reduction in symptoms 6-12 months from baseline as measured using the Vanderbilt ADHD Diagnostic Rating Scale, regardless of treatment prescribed. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (MUC ID: X3472)

  4. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (MUC ID: X3472)

  5. Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting (MUC ID: X4007)
    • Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current alcohol dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Substance use disorders: 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 (MUC ID: X4208)
    • Description: This measure is used to assess the 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. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current opioid dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


1:15 pm   Consent calendar 10: Cardiovascular conditions
There are five measures under consideration for the PQRS based programs, one is also for the EHR Incentive program. One composite measure is an updated measure previously finalized for PQRS with new specifications reflecting the latest guidelines. In 2015 PQRS has finalized fifteen measures for cardiovascular care addressing coronary artery disease, heart failure, hypertension and stroke.
Lead discussant(s): James Pacala, Diane Padden
  1. Optimal Vascular Care (MUC ID: E0076)
    • Description: Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use[For reference, description of endorsed measure from QPS: Percentage of adult patients ages 18 to 75 who have ischemic vascular disease with optimally managed modifiable risk factors (blood pressure, tobacco-free status, daily aspirin use).] (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Revised composite outcome measure (removed the lipid component due to new guidelines) to replace the prior version finalized in PQRS. Conditional on the revised measure being submitted for NQF endorsement. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: The measure conforms to new guidelines for statin use and should replace prior measures based on old guidelines. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Controlling High Blood Pressure (MUC ID: X3792)
    • Description: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on testing for reliability and validity at the clinician-level and review by NQF pending final hypertension guidelines from ACC due in 2015. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  5. Clinical Outcome post Endovascular Stroke Treatment (MUC ID: X3756)

  6. Door to puncture time for endovascular stroke treatment (MUC ID: X3747)

1:30 pm   Consent calendar 11: Asthma
The only asthma measure under consideration is a new composite measure containing two outcome components. The finalized PQRS measures include two process measures and one outcome measure that is included in the new composite.
Lead discussant(s): Marci Nielsen, Janis Orlowski
  1. Optimal Asthma Care 2014 (MUC ID: X3773)

  2. Optimal Asthma Care 2014 (MUC ID: X3773)

1:40 pm   Consent calendar 12: Diabetes and Renal
The measures under consideration include one new eMeasure for diabetes for PQRS based programs and the EHR Incentive program. Two measures for renal disease are under consideration for PQRS based programs. Diabetes and renal disease are conditions with numerous measures already finalized for PQRS 2015.
Lead discussant(s): Marci Nielsen, Janis ORlowski
  1. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)

  2. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)

  3. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)

  4. Pediatric Kidney Disease: Discussion of Care Planning (MUC ID: X3733)

1:50 pm   Consent calendar 13: Cognitive impairment/Dementia
Two new eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program. There are nine measures for dementia finalized for PQRS 2015.
Lead discussant(s): Constance Dahlin, Rachel Grob
  1. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)

  2. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)
    • Description: The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: The Medicare Annual Wellness Visit specifies "detection of any cognitive impairment". Although the USPSTF stated that the evidence is insufficient to recommend screening for cognitive impairment in asymptomatic population though age 80 years and above were not specifically addressed. Important for dual eligibles. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


2:00 pm   Consent calendar 14: Gastrointestinal conditions
There are two measures under consideration for the PQRS based programs and an episode based cost measure for the Value Based Payment Modifer (VBPM). There are six measures finalized for PQRS 2015 addressing aspects of colonoscopy performance and inflammatory bowel disease.
Lead discussant(s): Amy Mullins, Luther Clark
  1. Frequency of inadequate bowel preparation (MUC ID: X3760)

  2. Photodocumentation of cecal intubation (MUC ID: X3761)

  3. Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure (MUC ID: X0355)
    • Description: The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Gastrointestinal Hemorrhage episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a gastrointestinal hemorrhage hospital admission. The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the gastrointestinal hemorrhage treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Cost measures are required for VBPM. Quality measures are needed for GI hemorrhage to match with the cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


2:15 pm   Consent calendar 15: Perinatal
There are two similar outcome measures under consideration for the PQRS based programs. For 2015 there are four process measures and one outcome measures in this topic area finalized for PQRS.
Lead discussant(s): Cynthia Pellegrini, Terry Adirim
  1. Primary C-Section Rate 2014 (MUC ID: X3768)

  2. PC-02 Cesarean Section (Provider Level) (MUC ID: X3788)
    • Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding). (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Duplicative of measure under consideration X3768 that is already in use in private programs. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


2:25 pm   Consent calendar 16: Musculoskeletal conditions
There are three eMeasures under consideration for both PQRS based programs and the EHR Incentive program. Two measures in the new topic area of gout were recently evaluated by NQF for approval as “eMeasures for Trial Use”. In the musculoskeletal topic area, there are 22 measure finalized for PQRS in 2015 in the areas of functional status, rheumatoid arthritis, osteoporosis and osteoarthritis.
Lead discussant(s): David Seidenwurm, Mark Metersky
  1. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Support development as a functional patient-reported outcome eMeasure, not just  "score from one of a select list of pain interference assessment tools was recorded at least twice".  A PRO of improvement in pain associated with osteoarthritis fills a needed gap in PROs and functional status measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: See PQRS eMeasure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: This is the first measure for gout - a condition affecting more than 8 million Americans and affects African Americn men three times more than white men. Important for dual eligibles. NQF-approved eMeasure for Trial Use. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: NQF approved this eMeasure for Trial Use in 2014. Aligns wirth PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Gout: Serum Urate Monitoring (MUC ID: S2521)

  6. Gout: Serum Urate Monitoring (MUC ID: S2521)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


3:00 pm   Consent calendar 17: Neurology - headaches
Eleven measures are under consideration for the PQRS based programs for headaches including primary headache disorders, cluster headaches and migraines. This is a new topic area for PQRS.
Lead discussant(s): Jay Schuur, David Seidenwurm
  1. Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination (MUC ID: X3785)

  2. Quality Of Life Assessment For Patients With Primary Headache Disorders (MUC ID: X3786)

  3. Migraine Or Cervicogenic Headache Related Disability Functional Status (MUC ID: X3796)
    • Description: Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: This process measure documents functional status assessment. A better measure would determine whether the disability functional status score remained the same or improved during a recent timeframe simiar to MUC X3786 for Quality of Life. Conditional on testing at the clincian-level and submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  4. Overuse of Barbiturate Containing Medications for Primary Headache Disorders (MUC ID: X3765)

  5. MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK (MUC ID: X3771)

  6. Preventive Migraine Medication Prescribed (MUC ID: X3772)
    • Description: Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is >= 4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Measure of appropriate preventive treatment for patients with frequent migraines. Conditional on testing at the clincian-level and submission for NQF endorsement. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (MUC ID: X3766)

  8. Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders (MUC ID: X3783)

  9. Plan Of Care Or Referral For Possible Medication Overuse Headache (MUC ID: X3784)

  10. Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed (MUC ID: X3794)

  11. Overuse Of Opioid Containing Medications For Primary Headache Disorders (MUC ID: X3770)

3:30 pm   Consent calendar 18: Neurology - muscular dystrophy
Six new measures are under consideration for PQRS based programs in the new topic area of muscular dystrophy.
Lead discussant(s): Amy Mullins, Robert Krughoff
  1. Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy (MUC ID: X3787)
    • Description: All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Muscular dystrophy is a group of nine inherited diseases of progressive muiscle weakness affecting more than 50,000 Americans. This process measure in new condition area measures use of evidence-based therapy that can slow the progression of the disease. Conditional on satisfactory testing at the clincian-level and submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Patient Queried about Pain and Pain Interference with Function (MUC ID: X3800)

  3. Patient Counseled About Health Care Decision-Making (MUC ID: X3789)

  4. Scoliosis Evaluation Ordered (MUC ID: X3798)

  5. Nutritional Status or Growth Trajectories Monitored (MUC ID: X3801)

  6. MD Multidisciplinary Care Plan Developed or Updated (MUC ID: X3791)

3:45 pm   Consent calendar 19: Skin conditions
Two measures for PQRS in the new topic area of psoriasis including one outcome measure. There is also an episode based cost measure for cellulitis in development for the VBPM.
Lead discussant(s): Marci Nielsen, Amy Moyer
  1. Clinical Response to Oral Systemic or Biologic Medications (MUC ID: X3726)
    • Description: This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Outcome measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement.  (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Assessment for Psoriatic Arthritis (MUC ID: X3274)

  3. Cellulitis Clinical Episode-Based Payment Measure (MUC ID: X0354)
    • Description: The Cellulitis Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Cellulitis episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a cellulitis hospital admission. The Cellulitis Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Cellulitis Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the cellulitis treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Quality measures are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


3:55 pm   Consent calendar 20: Surgery - peri-operative and anesthesia
Six measures are under consideration for PQRS based programs. All are in development. There are very few measures finalized for PQRS 2015 in this topic area.
Lead discussant(s): Peter Briss, Bruce Sherman
  1. Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents (MUC ID: X3808)

  2. Anesthesiology Smoking Abstinence (MUC ID: X3811)

  3. Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination (MUC ID: X3806)
    • Description: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: This process measure includes evaluation of risk for PONV and adminstration of appropriate preventive medications. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Perioperative Temperature Management (MUC ID: X3809)
    • Description: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Intermediate outcome measure revised from a prior process measure. Additional measure for anesthesia. Recommend clarification of the specifications as discussed with the NQF Surgery Standing Committee in May 2014 as the measure is further developed and tested. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) (MUC ID: X3807)
    • Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for reliability and valdity and meaningful differences among anesthesia providers will be important. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) (MUC ID: X3810)
    • Description: Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for realiability and valdiity and meaningful differences among anesthesia providers will be important. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


4:05 pm   Consent calendar 21: Surgery - orthopedics
Two patient-reported outcome eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program. Additionally three episode based payment measures are under consideration for the VBPM.
Lead discussant(s): Eric Whitaker, Rachel Grob
  1. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)

  2. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)
    • Description: Average change in functional status assessment score for 19 years and older with primary total knee arthroplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)
    • Description: Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)

  5. Knee Replacement/ Revision Clinical Episode-Based Payment Measure (MUC ID: X0352)
    • Description: The Knee Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Knee Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a knee replacement/revision. The Knee Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Knee Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the knee replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Can be matched with 3 finalized measures for knee replacement in PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  6. Hip Replacement/ Revision Clinical Episode-Based Payment Measure (MUC ID: X0356)
    • Description: The Hip Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Hip Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a hip replacement/revision. The Hip Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Hip Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the hip replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 3
    • Preliminary analysis summary: Though surgery measures are finalized in PQRS, additional quality measures specific to hip replacedment are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. Spine Fusion/ Refusion Clinical Episode-Based Payment Measure (MUC ID: X0353)
    • Description: The Spine Fusion/Refusion Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Spine Fusion/Refusion episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a spine fusion/refusion. The Spine Fusion/Refusion Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Spine Fusion/Refusion Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the spine fusion/refusion performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Quality measure are needed for spine surgery to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


4:20 pm   Consent calendar 22: Surgery - vascular
Two measures are under consideration for the PQRS based programs including a mortality outcome measure.
Lead discussant(s): David Hopkins, Mark Metersky
  1. In-hospital mortality following elective open repair of AAAs (MUC ID: E1523)

  2. Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy (MUC ID: E0465)
    • Description: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery. [Note: Description is for update to NQF endorsed measure and differs from specifications provided in QPS] (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure. Evidence-based process measure that promotes secondary prevention of vasular disease beyond the timeframe of surgery. Complements two outcome measures for this procedure. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


4:30 pm   Consent calendar 23: Interventional radiology
Three measures for interventional radiology are under consideration for PQRS based programs including two outcome measures. All are in development.
Lead discussant(s): David Seidenwurm, Bruce Sherman
  1. Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment (MUC ID: X3739)

  2. Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal (MUC ID: X3755)

  3. Rate of surgical conversion from lower extremity endovascular revascularization procedure (MUC ID: X3754)

4:40 pm   Consent calendar 24: Genitourinary conditions
Eleven measures are under consideration for the PQRS based programs in the new topic area of pelvic prolapse surgery. Of these, three are adverse outcome measures. There is only one GU measure finalized for PQRS in 2015. An episode based payment measure for the VBPM is also under consideration.
Lead discussant(s): Beth Averbeck, Eric Whitaker
  1. Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury (MUC ID: X3752)

  2. Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair (MUC ID: X3743)

  3. Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair (MUC ID: X3813)

  4. Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair (MUC ID: X3744)

  5. Performing an intraoperative rectal examination at the time of prolapse repair (MUC ID: X3740)

  6. Preoperative assessment of sexual function prior to any pelvic organ prolapse repair (MUC ID: X3742)

  7. Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair (MUC ID: X3746)

  8. Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair (MUC ID: X3741)

  9. Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair (MUC ID: X3751)
    • Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP-Q or Baden/Walker) (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  10. Preoperative pessary for pelvic organ prolapse offered (MUC ID: X3750)

  11. Preoperative pessary for pelvic organ prolapse attempted (MUC ID: X3745)

  12. Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (MUC ID: X0351)
    • Description: The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Kidney/Urinary Tract Infection episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a kidney/urinary tract infection hospital admission. The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the kidney/urinary tract infection treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 4
    • Preliminary analysis summary: Quality measures are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


5:00 pm    Adjourn


Day 2  


8:30 am   MAP Feedback on 2015 Physician Fee Schedule Final Rule
Kate Goodrich, MD, CMS

9:15 am   Consent calendar 25: MSSP - Support
Three NQF-endorsed measures under consideration for MSSP.
Lead discussant(s): Amy Moyer, Amy Mullins
  1. Breast Cancer Screening (MUC ID: X3797)
    • Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the past 27 months. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


  2. Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy [Measure referred from hospital workgroup] (MUC ID: E0465)
    • Description: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery. [Note: Description is for update to NQF endorsed measure and differs from specifications provided in QPS] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This fully developed and tested endorsed measure assessesaddresses the safety of patients by evaluatingappropriate use of medications before and after procedure. It also requires a level of coordination and collaboration within ACO.  (Full Preliminary Analysis)
    • Preliminary analysis result: Support


  3. In-hospital mortality following elective open repair of AAAs [Measure referred from hospital workgroup] (MUC ID: E1523)
    • Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure represents an important cardiac outcome for a large number of Medicare beneficiaries. This measure is currently used by private sector registries, and is undery consideration for the other PQRS-based programs. While the measure does not address care across settings, and providers, it does represent an important opportunity for quality improvement in the Medicare FFS population. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


9:45 am   Consent calendar 26: MSSP - Conditional Support
Eighteen measures under consideration are conditionally supported for the MSSP. These measures should be submitted to NQF for review and endorsement.
Lead discussant(s): Janis Orlowski, Rachel Grob
  1. Prevention Quality Indicators #90 (PQI #90) (MUC ID: X3715)
    • Description: Prevention Quality Indicators (PQI) overall composite per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Requires testing at ACO level. Need to consider appropriateness of conditions within composite for Medicare FFS population. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Optimal Asthma Care 2014 (MUC ID: X3773)
    • Description: Composite (“optimal” care) measure of the percentage of pediatric and adult patients who have asthma and meet specified targets to control their asthma. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important composite measure with patient-reported outcome measure component measure. Updated measure will be submitted to NQF for endorsement review. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  3. Optimal Vascular Care (MUC ID: E0076)
    • Description: Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use[For reference, description of endorsed measure from QPS: Percentage of adult patients ages 18 to 75 who have ischemic vascular disease with optimally managed modifiable risk factors (blood pressure, tobacco-free status, daily aspirin use).] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Composite outcome measure for highly prevalent condition important to Medicare patients. Conditonal on successful maintenace review of revised measure by NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  4. Coronary Artery Disease (CAD): Symptom Management: (MUC ID: X1033)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measure assesses patient-reported activity and management. Conditional support pending submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  5. Depression Utilization of the PHQ-9 Tool (MUC ID: E0712)
    • Description: Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD-9 296.2x, 296.3x or 300.4) who have a PHQ-9 tool administered at least once during the four month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure intended to be paired with one of two outcome measures - Depression Remission at 6 month and Depresion Remission at 12 months; condiitonal on pairing with either or both outcome measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  6. Depression Remission at Six Months (MUC ID: E0711)
    • Description: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (± 30 days) PHQ-9 score of less than five. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Support a depression outcome measure for MSSP. Should align with other federal programs. PQRS measure focused on 12 month remission. Recommend pairing with measure 0712 Use of PHQ9. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. Controlling High Blood Pressure (MUC ID: X3792)
    • Description: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on review by NQF pending final hypertension guidelines from ACC due in 2015. Existing BP control measure already in MSSP program. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  8. Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination (MUC ID: X3785)
    • Description: Percentage of patients with a diagnosis of primary headache disorder with a normal neurological examination* for whom advanced brain imaging (CTA, CT, MRA or MRI) was NOT ordered. [NQF edit] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Conditional on measure testing and submission to NQF for endorsement. Multiple headache measures may be appropriate for a MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  9. Quality Of Life Assessment For Patients With Primary Headache Disorders (MUC ID: X3786)
    • Description: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important PROM appropriate for clinician level measurement; may be too narrow for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  10. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support.


  11. Documentation of Signed Opioid Treatment Agreement (MUC ID: X3777)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  12. Consideration of Non-Pharmacologic Interventions (MUC ID: X3776)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration with whom the clinician discussed non-pharmacologic interventions (e.g. graded exercise, cognitive/behavioral therapy, activity coaching at least once during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to alternatives to chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  13. Chronic Opioid Therapy Follow-up Evaluation (MUC ID: X3775)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  14. TOTAL PER CAPITA COST MEASURE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES (MUC ID: X2147)
    • Description: The ratio of all actual Medicare FFS Parts A and B payments to a medical group practice for beneficiaries attributed to it over a calendar year to all expected payments to the medical group practice, multiplied by the payment for the average beneficiary in the sample. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Meet MSSP programmatic objectives. Support pending submission of revised measure to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  15. Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3743)
    • Description: Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This importantoutcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  16. Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3744)
    • Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscous at the time of index surgery that is recognized intraoperative or within 1 month after surgery (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This important outcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  17. Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3813)
    • Description: Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary:   Conditional Support pending NQF review and endorsement (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  18. Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury [Measure referred from hospital workgroup] (MUC ID: X3752)

   Consent calendar 27: MSSP - Encourage further development
Of 56 measure under consideration that are still in development, 38 are recommended for continued development for potential use in MSSP.
Lead discussant(s): Mark Metersky, David Hopkins
  1. Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure (MUC ID: X3481)
    • Description: Percentage of patients aged 65 years and older with congestive heart failure who had a target improvement goal defined after completing an initial patient-reported functional status assessment and met the goal after completing a follow-up functional status assessment (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures such as patient-reported outcomes in the area of functional status measures. However, this measure needs further development and testing to be ready for implementation. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)
    • Description: Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)
    • Description: Average change in functional status assessment score for 19 years and older with primary total knee arthroplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Clinical Outcome post Endovascular Stroke Treatment (MUC ID: X3756)
    • Description: Patients with 90 day mRs score of 0 to 2 post endovascular stroke intervention (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important patient-function measure after stroke treatment. Ideally, broader patient population would be preferable for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage further development


  5. Extravasation of contrast following contrast-enhanced computed tomography (CT) (MUC ID: X3523)
    • Description: Percentage of final reports for patients aged 18 years and older who received intravenous iodinated contrast for a computed tomography (CT) examination who had an extravasation of contrast Lower performance rate is the goal. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important adverse event for hospital setting; may not add value for ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Appropriate age for colorectal cancer screening (MUC ID: X3758)
    • Description: Percentage of average-risk patients age 86 or older who underwent screening colonoscopy (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary: Important area of potential overuse in Medicare population. Need to consider harmonization/selection among competing measures colonoscopy overuse measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Unnecessary Screening Colonoscopy in Older Adults (MUC ID: X3769)
    • Description: Percentage of patients age 86 or older who received an unnecessary screening colonoscopy. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important overuse measure for common screening test. Need to reconcile across competing colonoscopy overuse measure (including X3758). (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  8. Appropriate follow-up imaging for non-traumatic knee pain (MUC ID: X3802)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic knee pain who undergo knee magnetic resonance imaging (MRI) or magnetic resonance arthrography (MRA) who are known to have had knee radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  9. Appropriate use of imaging for non-traumatic shoulder pain (MUC ID: X3803)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  10. Communication and shared decision-making with patients and families for interventional oncology procedures (MUC ID: X3735)
    • Description: Percentage of patients who have undergone an interventional oncology ablation or catheter-directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was discussed with the patient and/or family member (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Reflects shared decisionmaking for medically complex patients. Optimally would include patient voice. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  11. Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding (MUC ID: X3780)

  12. Frequency of inadequate bowel preparation (MUC ID: X3760)
    • Description: The percentage of outpatient examinations with “inadequate” bowel preparation that require repeat colonoscopy in one year or less (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 3
    • Preliminary analysis summary: Important measure regarding colonoscopy preparation. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  13. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Care coordination is a priority for Medicare patients and a good assement of an ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  14. Closing the Referral Loop - Specialist Report Sent to Primary Care Physician (MUC ID: X3302)
    • Description: Percentage of referrals received for which the receiving provider sent a consultant report back to the referring provider. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Care coordination across providers is a critical program objective. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  15. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions. Encourage harmonization with PCPI regarding transition record measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  16. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  17. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High priority area. Meets program objective for risk assessment and intervention. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  18. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Dementia is a high priority area for Medicare. Results of cognitive assessment will be captured in EHR. Need to consider insufficient rating from USPSTF due to lack of evidence that early screening or intervention improves outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  19. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)
    • Description: The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Healthcare proxy requires coordination across providers. High priority area for Medicare and MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  20. Comprehensive Diabetes Care: Eye Exam (MUC ID: E0055)
    • Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who received a retinal or dilated eye exam during the measurement year or a negative retinal or dilated eye exam in the year prior to the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure for diabetes; requires coordination to ensure care delivery and documentation. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  21. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)
    • Description: Percentage of patients 65 years of age and older with diabetes who had hemoglobin A1c < 7.0% during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Submission to NQF for review. Age cut-off at 65 years needs further review (highly dependent on functional status and related co-morbidities) (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  22. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)
    • Description: Percentage of patients aged 15 to 34 seen in the ER for injury who were screened for hazardous alcohol use AND provided a brief intervention within 7 days of the ER visit if screened positive. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  23. Imaging in adult ED patients with minor head injury (MUC ID: X3764)
    • Description: Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) <=15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of appropriateness for MSSP. Need to consider competing measures related to ED imaging (NQF#0668). (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  24. Photodocumentation of cecal intubation (MUC ID: X3761)
    • Description: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary: Important measure regarding colonoscopy adequacy. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  25. Appropriate follow-up imaging for incidental abdominal lesions (MUC ID: X3759)
    • Description: Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: - liver lesion < 1.5 cm - kidney lesion < 1.0 cm - adrenal lesion < 4.0 cm Lower performance rate is goal (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: High value measure of potential imaging overuse. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  26. Appropriate follow-up imaging for incidental thyroid nodules in patients (MUC ID: X3763)
    • Description: Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended Lower performance rate is goal. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measure related to imaging overuse. It may be somewhat narrow for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  27. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Multiple measures related to INR monitoring for certain conditions (e.g., atrial fibrillation). Measures should be harmonized with preference for outcome, including time in therapeutic range. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  28. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Appropriate for MSSP program. Requires coordination of care across providers. If possible, should incorporate outcome for time in therapeutic range. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  29. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Meets program objectives. Could be appropriate PROM for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  30. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician measure in gap area. New eMeasure to be tested. Not appropriate for MSSP program. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  31. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)
    • Description: Percentage of female patients aged 15-40 years old who were screened for intimate partner (domestic) violence at any time during the reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  32. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Population screening for alcohol dependence; support development for PRS and EHR Incentive also. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  33. Substance Use Screening and Intervention Composite (MUC ID: X3475)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 4
    • Preliminary analysis summary: Important area of focus; new eMeasure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  34. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Supports appropriate referral to hospice. Reflects coordination and collaboration across ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  35. Door to puncture time for endovascular stroke treatment [Measure referred from hospital workgroup] (MUC ID: X3747)
    • Description: Door to puncture time less than 2 hours for patients undergoing endovascular stroke treatment (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: This intermediate clinical timeliness of appropriate stroke treatment outcome measure is important for a leading cause of mortality and disability for the Medicare fee-for-service population. The measure promotes alignment across the PQRS-based programs. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  36. Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination [Measure referred from hospital workgroup] (MUC ID: X3806)
    • Description: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: This measure addresses an important area for potential surgical care improvement for Medicare beneficiaries. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  37. Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) [Measure referred from hospital workgroup] (MUC ID: X3807)
    • Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for in the OR and are transferred to the ICU andencourages coordination within an acute care facility among providers. The measure also has the potential to improve surgical and anesthesia care for the Medicare population.  (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  38. Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) [Measure referred from hospital workgroup] (MUC ID: X3810)
    • Description: Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU). The measure does encourage coordination within an acute care facility among providers. The measure does have the potential to improve surgical and anesthesia care for the Medicare population.  (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


10:30 am   Consent calendar 28: MSSP -Do not support
Thirty fully developed measures are not supported for MSSP. Some do not apply to the Medicare population and others address very narrow conditions or patient populations.
Lead discussant(s): Davis Seidenwurm, Robert Krughoff
  1. Coronary Artery Disease (CAD): Antiplatelet Therapy (MUC ID: E0067)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Optimal Vascular Care measure (E0076) contains this measure as a component of the composite. Both measures would be redundant. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  2. Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) (MUC ID: E0070)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy There are two reporting criteria for this measure: (1) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% OR (2) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have prior myocardial infarction"[For reference, descriptin of endorsed measure from QPS: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinical measure that does not reflect MSSP program objectives. Beta blocker persistence ( NQF #71) measure may better reflect care across continuum. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  3. Overuse of Barbiturate Containing Medications for Primary Headache Disorders (MUC ID: X3765)
    • Description: Percentage of patients age 18 years old and older with a diagnosis of primary headache who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  4. ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (MUC ID: X3766)
    • Description: Percentage of patients age 18 years old and older with a diagnosis of cluster headache (CH) who were prescribed a guideline recommended acute medication for cluster headache within the 12-month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  5. Overuse Of Opioid Containing Medications For Primary Headache Disorders (MUC ID: X3770)
    • Description: Percentage of patients aged 12 years and older diagnosed with primary headache disorder and taking opioid containing medication who were assessed for opioid containing medication overuse within the 12-month measurement period and treated or referred for treatment if identified as overusing opioid containing medication. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  6. MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK (MUC ID: X3771)
    • Description: Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  7. Preventive Migraine Medication Prescribed (MUC ID: X3772)
    • Description: Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is >= 4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  8. Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders (MUC ID: X3783)
    • Description: Percentage of patients diagnosed with a primary headache disorder, who are actively taking an acute headache medication and experiencing headaches >= 15 days per month for 3 months, who were assessed for medication overuse headache (MOH). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  9. Plan Of Care Or Referral For Possible Medication Overuse Headache (MUC ID: X3784)
    • Description: Percentage of patients diagnosed with medication overuse headache (MOH) within the past 3 months or who screened positive for possible MOH (measure 6a) who had a medication overuse plan of care created or who were referred for this purpose. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  10. Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed (MUC ID: X3794)
    • Description: All patients diagnosed with migraine headache or cervicogenic headache who had a headache management plan of care developed or reviewed at least once during the 12 month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  11. Migraine Or Cervicogenic Headache Related Disability Functional Status (MUC ID: X3796)
    • Description: Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  12. Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair (MUC ID: X3741)
    • Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  13. Preoperative assessment of sexual function prior to any pelvic organ prolapse repair (MUC ID: X3742)
    • Description: Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  14. Preoperative pessary for pelvic organ prolapse attempted (MUC ID: X3745)
    • Description: The percentage of patients who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  15. Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair (MUC ID: X3746)
    • Description: Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure addresses a gap in speciality measurement. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  16. Preoperative pessary for pelvic organ prolapse offered (MUC ID: X3750)
    • Description: The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not relate to MSSP program objectives. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  17. Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair (MUC ID: X3751)
    • Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP-Q or Baden/Walker) (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  18. Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy (MUC ID: X3787)
    • Description: All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  19. Patient Counseled About Health Care Decision-Making (MUC ID: X3789)
    • Description: All patients with a diagnosis of a muscular dystrophy (MD), or their caregivers who were counseled about advanced health care decision making, palliative care, or end-of-life issues at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  20. MD Multidisciplinary Care Plan Developed or Updated (MUC ID: X3791)
    • Description: All patients diagnosed with a muscular dystrophy (MD) for whom a MD multi-disciplinary care plan was developed, if not done previously, or the plan was updated at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  21. Scoliosis Evaluation Ordered (MUC ID: X3798)
    • Description: All visits for patients with a diagnosis of a muscular dystrophy (MD) where the patient had a scoliosis evaluation ordered. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  22. Patient Queried about Pain and Pain Interference with Function (MUC ID: X3800)
    • Description: All visits for patients diagnosed with a muscular dystrophy (MD) where the patient was queried about pain and pain interference with function using a validated and reliable instrument. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  23. Nutritional Status or Growth Trajectories Monitored (MUC ID: X3801)
    • Description: All visits for patients diagnosed with muscular dystrophy (MD) where the patient’s nutritional status or growth trajectories were monitored. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  24. Primary C-Section Rate 2014 (MUC ID: X3768)

  25. PC-02 Cesarean Section (Provider Level) (MUC ID: X3788)
    • Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure. Not appropriate for Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  26. Cervical Cancer Screening (MUC ID: E0032)
    • Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21-64 who had cervical cytology performed every 3 years. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: A good measure for ACOs in general, but not applicable to the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  27. Assessment for Psoriatic Arthritis (MUC ID: X3274)
    • Description: This measure evaluates the number of all psoriasis patients who are screened for psoriatic arthritis. Doing this helps to prevent structural damage, and maximizes quality of life (QOL). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Narrow topic area - better for clinicians/specialists. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  28. Clinical Response to Oral Systemic or Biologic Medications (MUC ID: X3726)
    • Description: This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  29. ALS Multidisciplinary Care Plan Developed or Updated (MUC ID: X2809)
    • Description: Percentage of patients diagnosed with ALS for whom a multi-disciplinary care plan was developed, if not done previously, and the plan was updated at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure captures very few Medicare patients. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  30. Performing an intraoperative rectal examination at the time of prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3740)
    • Description: Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior prolapse. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This process measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.  (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


11:00 am   Consent calendar 29: MSSP -Do not encourage further consideration
Eighteen measures in development are not recommended for further consideration for MSSP.
Lead discussant(s): Jay Schuur, James Pacala
  1. Diabetes: Foot exam (MUC ID: E0056)
    • Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Diabetes process measure that does not reflect care across continuum or coordination of services. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  2. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)
    • Description: Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Health risk screening with follow-up. Could possibly be combined with isolated screening measure (x3512). Most appropriate for duals population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  3. HIV medical visit frequency (MUC ID: E2079)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression) (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  4. HIV Viral Load Suppression (MUC ID: E2082)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. This intermediate outcome measure preferred to HIV process measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  5. Prescription of HIV Antiretroviral Therapy (MUC ID: E2083)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression) (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  6. Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy (MUC ID: X3781)
    • Description: Percentage of final reports for patients aged 18 years and older who had a previously documented contrast reaction who undergo any imaging examination using intravenous iodinated contrast that include documentation that the patients were pre-medicated with corticosteroids with or without H1 antihistamines (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  7. Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment (MUC ID: X3739)
    • Description: Percentage of patients treated for varicose veins (CEAP C2) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that receive a disease specific patient reported outcome survey before and after treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. Preference for PROM with patient results. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  8. Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal (MUC ID: X3755)
    • Description: Proportion of patients in whom a retrievable IVC filter is placed who, within 3 months post- placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  9. Gout: Serum Urate Monitoring (MUC ID: S2521)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: NQF did not approve this eMeasure for trial Use due to lack of evidence of relationship to patient outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  10. Use of Imaging Studies for Low Back Pain (MUC ID: E0052)
    • Description: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measures applies to ages 18-50 years. Not applicable to the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  11. HIV Screening of STI patients (MUC ID: X3300)

  12. HIV: Ever screened for HIV (MUC ID: X3299)

  13. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users (MUC ID: X3513)
    • Description: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  14. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)
    • Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received a one-time screening for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  15. Rate of surgical conversion from lower extremity endovascular revascularization procedure (MUC ID: X3754)
    • Description: In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  16. Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents [Measure referred from hospital workgroup] (MUC ID: X3808)
    • Description: Percentage of patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to surgical start time (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: While an important clinical measure, it does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  17. Perioperative Temperature Management [Measure referred from hospital workgroup] (MUC ID: X3809)
    • Description: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure has been retired by the measure steward, CMS. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  18. Anesthesiology Smoking Abstinence [Measure referred from hospital workgroup] (MUC ID: X3811)
    • Description: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Smokingcessation is an important area of measurement; however single day abstinence does not reflect the objective of a high value measure of health risk with follow-up intervention. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


11:45 am   Discussion of gaps in the Clinician Quality Programs


12:45 pm   Discussion of Programmatic Deliverable


2:00 pm   Adjourn


Appendix A: Preliminary Analysis

Preliminary Analysis Index


Full Preliminary Analysis

ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3766)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Cluster headaches are underdiagnosed and undertreated. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS strategy for promoting the most effective prevention and treatment practices

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CH is under diagnosed and undertreated. Although CH has a much lower prevalence than many other types of headache, it is often considered the most severe headache pain. Suicidality ideations in one study were as high as 55% of the study population.


ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE for program(s): MSSP (MUC ID: X3766)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: CH is under diagnosed and undertreated. Although CH has a much lower prevalence than many other types of headache, it is often considered the most severe headache pain. Suicidality ideations in one study were as high as 55% of the study population.


ADHD: Symptom Reduction in Follow-up Period for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3280)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Hight-value, patient reported outcome measure. 

Does the measure address a critical program objective as defined by MAP? Yes. This patient reported outcome is a high value measure that fills a noted gap in pediatric behavioral health measurement.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No. Measure currently being tested.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: According to the CDC, approximately 9% of children age 4-17 have ADHD and the rate of ADHD diagnosis has increased an average of 5% per year from 2003 to 2007. Evidence exists that shows there is a lack of a standard approach to ADHD diagnosis and adherence to treatment guidelines. One likely cause of the poor provision of ADHD care is the logistical issue surrounding collection of ADHD rating scales from parents and teachers. Collection of rating scales requires knowledge of appropriate ratings scales to use, time to explain the purpose of collecting rating scales to parents, distribution of rating scales to and from home, coordination of distributing and collecting rating scales from school, scoring of completed ratings, and, finally, interpretation of results. This comprises a complex data management process that typically goes un- or under-reimbursed in pediatric settings. Without the collection of these results, the quality of ADHD care suffers. ADHD Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. AAP 2011. Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity. Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. For pharmacologic treatment, the primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation) ADHD Process-of-Care Algorithm, Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition. AAP 2011. Continued systematic monitoring (to include reconsideration of the diagnosis if improvements in symptoms are not apparent) is an on-going process, to be addressed throughout the child’s/adolescent’s care within the practice. Clinicians should regularly monitor all aspects of ADHD treatment, to include: - Systematic reassessment of core symptoms and function; - Regular reassessment of target goals; - Assurance that the family is satisfied with the care they are receiving from other clinicians and therapists, if applicable; - Provision of anticipatory guidance, further child/adolescent and family education, and transition planning as needed and appropriate; - Assurance that care coordination is occurring and meeting the needs of the child/adolescent and family; - Confirmation of adherence to any prescribed medication regimen, with adjustments made as needed; - Heart rate, blood pressure, height, and weight monitoring; and - Continuing to form a therapeutic relationship with the child/adolescent and empower families and children/adolescents to be strong, informed advocates.


ADHD: Symptom Reduction in Follow-up Period for program(s): MUEP (MUC ID: X3280)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. PRO

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: According to the CDC, approximately 9% of children age 4-17 have ADHD and the rate of ADHD diagnosis has increased an average of 5% per year from 2003 to 2007. Evidence exists that shows there is a lack of a standard approach to ADHD diagnosis and adherence to treatment guidelines. One likely cause of the poor provision of ADHD care is the logistical issue surrounding collection of ADHD rating scales from parents and teachers. Collection of rating scales requires knowledge of appropriate ratings scales to use, time to explain the purpose of collecting rating scales to parents, distribution of rating scales to and from home, coordination of distributing and collecting rating scales from school, scoring of completed ratings, and, finally, interpretation of results. This comprises a complex data management process that typically goes un- or under-reimbursed in pediatric settings. Without the collection of these results, the quality of ADHD care suffers. ADHD Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. AAP 2011. Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity. Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. For pharmacologic treatment, the primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation) ADHD Process-of-Care Algorithm, Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition. AAP 2011. Continued systematic monitoring (to include reconsideration of the diagnosis if improvements in symptoms are not apparent) is an on-going process, to be addressed throughout the child’s/adolescent’s care within the practice. Clinicians should regularly monitor all aspects of ADHD treatment, to include: - Systematic reassessment of core symptoms and function; - Regular reassessment of target goals; - Assurance that the family is satisfied with the care they are receiving from other clinicians and therapists, if applicable; - Provision of anticipatory guidance, further child/adolescent and family education, and transition planning as needed and appropriate; - Assurance that care coordination is occurring and meeting the needs of the child/adolescent and family; - Confirmation of adherence to any prescribed medication regimen, with adjustments made as needed; - Heart rate, blood pressure, height, and weight monitoring; and - Continuing to form a therapeutic relationship with the child/adolescent and empower families and children/adolescents to be strong, informed advocates.


Adult Kidney Disease: Referral to Hospice for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3732)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure addressess patient-centered care, end of life care and is a priority for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure that focuses on patient- and family-centered care and end-of life care.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Also tested at individual practice; group practice level

Is the measure currently in use? Yes. QCDR

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi-professional team with expertise in renal palliative care, including nephrology professionals, family or community-based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end-of-life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Adult Kidney Disease: Referral to Hospice for program(s): MSSP (MUC ID: X3732)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Supports appropriate referral to hospice. Reflects coordination and collaboration across ACO.

Does the measure address a critical program objective as defined by MAP? Yes. Encourages coordination across providers and lifespan.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Proposed for multiple federal programs. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi-professional team with expertise in renal palliative care, including nephrology professionals, family or community-based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end-of-life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: Related to PQRS measure #380 (intermediate outcome) addressing warfarin use in patients with atrial fibrillation. This measure is duplicative and not harmonized with NQF-endorsed measure under consideration E0555 that applies to a broader population of all patients taking warfarin.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety process eMeasure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. The measure is being tested at the clinician level.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. PQRS measure #380 is an intermediate outcome measure addressing the same population and care process. This measure is also duplicative and not harmonized with NQF-endorsed measure under consideration E0555.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): MUEP (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): MSSP (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Multiple measures related to INR monitoring for certain conditions (e.g., atrial fibrillation). Measures should be harmonized with preference for outcome, including time in therapeutic range.

Does the measure address a critical program objective as defined by MAP? Yes. Improve coordination for patients with chronic conditions

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): MUEP (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: EHR measure limited to patients aged 15-34 years presenting to ED with trauma - a screening measure with follow-up. Measure is high-priority area for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Screening of ED patients aged 15-34 years with trauma.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . It is likely this measure can be applied at a clinician level.

Is the measure currently in use? Yes. This measure is used by the Indian Health Services in its Clinical Reporting System (CRS) National Measures Report and Selected Measures (Local) Report

Does a review of its performance history raise any concerns? No. No performance data available.

Does the measure promote alignment and parsimony? Yes. The measure is already used by the Indian Health Services and could be used across a variety of settings. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is not endorsed, but a similar measure from the PCPI, "Unhealthy Alcohol Use: Screening and Brief Counseling" is endorsed for use at the clinician level.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): MSSP (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of health risk with follow-up interventions. However, age cut-off for measure excludes most FFS Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Proposed for use across multiple programs. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


ALS Multidisciplinary Care Plan Developed or Updated for program(s): MSSP (MUC ID: X2809)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: This measure captures very few Medicare patients.

Does the measure address a critical program objective as defined by MAP? No. 00 new cases /year in US. Average age is 55 years. Average life expectancy is 2-5 years. Not a significant impact on the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No information on testing.

Is the measure currently in use? No. A new measure.Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: In specialized multidisciplinary clinics, patients with ALS receive comprehensive care from a neurologist, pulmonologist, gastroenterologist, physiatrist, social worker, occupational therapist, speech language pathologist, respiratory therapist, specialized nurse case manager, physical therapist, dietitian, psychologist, dentist, and/or palliative care expert.1,2 Moreover, the level of satisfaction with the rendering of the diagnosis and overall satisfaction with care is significantly higher for patients attending a multidisciplinary clinic.2 Specialized clinics coordinate care and interface with a primary care physician, local neurologist and community-based services. Patients who attend specialized ALS clinics are younger and have longer symptom duration than neurology clinic patients, indicating possible referral bias.3 Patient care and survival were examined for 97 patients attending specialized ALS clinics in Italy compared with 124 patients in neurology clinics.4 There was increased utilization of riluzole, percutaneous endoscopic gastrostomy (PEG), and noninvasive ventilation (NIV) in the ALS clinics, and fewer hospital admissions. Mean survival was longer in specialized ALS clinics (1,080 days vs. 775 days, p=0.008). Using COX multivariate analysis, attending an ALS specialized clinic independently predicted longer survival for patients. Prolonged survival (7.5 months, p<0.0001) was found for patients in Ireland attending multidisciplinary ALS clinics.5 Patients at ALS clinics were younger and more likely to receive riluzole (99% vs. 61%). Multidisciplinary care was an independent predictor of survival (p=0.02) and reduced the risk of death by 47% in a 5-year study.5 Dutch patients in multidisciplinary ALS clinics (n=133) were compared with 75 patients receiving general care6 (6). Patients were well-matched and data were collected by a blinded nurse. Patients in multidisciplinary clinic received more aids and appliances (93% vs. 81%, p =0.008) and had higher quality of life (SF-36® Health Survey, p <0.01). Beneficial effects derived from a single visit to a multidisciplinary clinic, suggesting better coordination of care. Importantly, patients attending multidisciplinary clinics had fewer hospital admissions and shorter inpatient stays than those cared for in the community.


Amblyopia Screening in Children for program(s): MUEP (MUC ID: X3817)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligned with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure for children.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Vision problems are commonplace among children and adolescents, affecting 25 percent of children five to 17 years of age. Problems specific to children include strabismus, color vision defects, refractive error, reduced visual acuity and amblyopia. Amblyopia, also known as lazy eye, affects nearly 500,000 preschoolers and is the primary cause of permanent vision loss among children of any age. Early detection, treatment and follow-up are critical in preventing and managing vision disorders. Undetected vision problems affect up to 10 percent of preschool-aged children. Fewer than 15 percent of all preschool children receive an eye examination and less than 22 percent of preschool children receive some type of vision screening. Early screening can lead to the detection of amblyopia (2-5%), strabismus (3-4%), and significant refractive error (15-20%), the most prevalent and significant vision disorders of preschool children. The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. The AAP recommends that all children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


Amblyopia Screening in Children for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3817)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. (Grade B)

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure for children.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure designated to report at the clinician level, however no testing data is available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Vision problems are commonplace among children and adolescents, affecting 25 percent of children five to 17 years of age. Problems specific to children include strabismus, color vision defects, refractive error, reduced visual acuity and amblyopia. Amblyopia, also known as lazy eye, affects nearly 500,000 preschoolers and is the primary cause of permanent vision loss among children of any age. Early detection, treatment and follow-up are critical in preventing and managing vision disorders. Undetected vision problems affect up to 10 percent of preschool-aged children. Fewer than 15 percent of all preschool children receive an eye examination and less than 22 percent of preschool children receive some type of vision screening. Early screening can lead to the detection of amblyopia (2-5%), strabismus (3-4%), and significant refractive error (15-20%), the most prevalent and significant vision disorders of preschool children. The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. The AAP recommends that all children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


Anesthesiology Smoking Abstinence for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3811)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Intermediate outcome measure of smoking cessation at least for the day of surgery. Longer smoking cessation before surgery is better, but cessation on the day of surgery confers some benefit to patients.

Does the measure address a critical program objective as defined by MAP? Yes. This is an intermediate-outcome measure that satisifes a gap area in its' assessment of patients who stop smoking the day of surgery or procedure. An additional measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Each year, millions of cigarette smokers require surgery and anesthesia in the US. Smoking is a significant independent risk factor for perioperative heart, lung, and wound-related complications. There now is good evidence that perioperative abstinence from smoking reduces the risk of heart, lung, and wound-related perioperative complications, and that the perioperative period represents a “teachable moment” for smoking cessation that improves long-term abstinence rates; over 100,000 smokers quit in the US each year as a result of having a surgical procedure. Although evidence suggests that the longer the duration of abstinence the better, there is also evidence that even brief abstinence (e.g., abstaining from smoking on the morning of surgery) can dramatically reduce both nicotine and carbon monoxide levels and reduce risks for complications such as intraoperative myocardial ischemia. Evidence shows that tobacco interventions can 1) increase perioperative abstinence rates in surgical patients who smoke and 2) decrease the rate of perioperative complications. Thus, this measure, which incents the provision of tobacco interventions by clinicians as a part of routine clinical practice, will significantly improve the health of smokers who require surgery. In its Clinical Practice Guideline for Treating Tobacco Use and Dependence, the US Public Health Services recognizes the important role that clinicians play in delivering tobacco use intervention services, strongly recommending that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.


Anesthesiology Smoking Abstinence [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3811)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: Smokingcessation is an important area of measurement; however single day abstinence does not reflect the objective of a high value measure of health risk with follow-up intervention.

Does the measure address a critical program objective as defined by MAP? Yes.  Smokingcessation is an important area of measurement; however single day abstinence does not reflect the objective of a high value measure of health risk with follow-up intervention.·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: This measure has limited potential toaddress the objective of a high value measure of health risk with follow-up intervention for Medicare beneficaires.·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response:  This measure doesn’t directly address the rate of growth of healthcare spending. ·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not measure care across settings or providers. ·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure is currently under consideration in PQRS-based programs. If it is selected for use in these programs, this can promote alignment in the future. ·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This measure has limited potential toaddress the objective of a high value measure of health risk with follow-up intervention for Medicare beneficaires

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs. 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Each year, millions of cigarette smokers require surgery and anesthesia in the US. Smoking is a significant independent risk factor for perioperative heart, lung, and wound-related complications. There now is good evidence that perioperative abstinence from smoking reduces the risk of heart, lung, and wound-related perioperative complications, and that the perioperative period represents a “teachable moment” for smoking cessation that improves long-term abstinence rates; over 100,000 smokers quit in the US each year as a result of having a surgical procedure. Although evidence suggests that the longer the duration of abstinence the better, there is also evidence that even brief abstinence (e.g., abstaining from smoking on the morning of surgery) can dramatically reduce both nicotine and carbon monoxide levels and reduce risks for complications such as intraoperative myocardial ischemia. Evidence shows that tobacco interventions can 1) increase perioperative abstinence rates in surgical patients who smoke and 2) decrease the rate of perioperative complications. Thus, this measure, which incents the provision of tobacco interventions by clinicians as a part of routine clinical practice, will significantly improve the health of smokers who require surgery. In its Clinical Practice Guideline for Treating Tobacco Use and Dependence, the US Public Health Services recognizes the important role that clinicians play in delivering tobacco use intervention services, strongly recommending that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.


Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users for program(s): MSSP (MUC ID: X3513)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen.

Does the measure address a critical program objective as defined by MAP? No. Screening measure for population health, though not as relevant to Medicare FFS population. Does not require follow-up intervention if positive. Could be appropriate for duals.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The U.S. Preventive Services Task Force (USPSTF)40 recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. The most important risk factor for HCV infection is past or current injection drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection status44,45,46,47; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status.


Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users for program(s): MUEP (MUC ID: X3513)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure is already in PQRS and is a high priority quality issue for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Population health screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment with PQRS #387.This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The U.S. Preventive Services Task Force (USPSTF)40 recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. The most important risk factor for HCV infection is past or current injection drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection status44,45,46,47; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status.


Appropriate age for colorectal cancer screening for program(s): MSSP (MUC ID: X3758)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important area of potential overuse in Medicare population. Need to consider harmonization/selection among competing measures colonoscopy overuse measures.

Does the measure address a critical program objective as defined by MAP? Yes. Reflects potential overuse of importance to Medicare population

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). Overuse of screening colonoscopy in patients age 86 or older is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365).


Appropriate age for colorectal cancer screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3758)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is duplicative of measure under consideration X3769. Harmonizatiopn and consolidation to one measure is needed.

Does the measure address a critical program objective as defined by MAP? Yes. The is an appropriate use population screening measure that complements the PQRS measure #113 (NQF #0034).

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure not yet tested.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No. This is duplicative of measure under consdieration X3769.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). Overuse of screening colonoscopy in patients age 86 or older is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365).


Appropriate follow-up imaging for incidental abdominal lesions for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3759)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value, ppropriate use of imaging measure. in development.

Does the measure address a critical program objective as defined by MAP? . Addresses NQS strategy; Process measure; Accounts for a wide population (18+);

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? No.

Is the measure currently in use? No. No other programs listed.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Incidental kidney, liver, and adrenal lesions are commonly found during abdominal imaging studies, with most of the findings being benign 1,2,3,4, 5. Given the low rate of malignancy, unnecessary follow-up procedures are costly and present a significant burden to patients1,6. To avoid excessive testing and costs, follow-up is not recommended for these small lesions. 1. Pickhardt PJ, Hanson ME, Vanness DJ, et al. Unexpected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology. 2008;249(1):151-159. doi:10.1148/radiol.2491072148. 2. Yee J, Kumar NN, Godara S, et al. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology. 2005;236:519-526. doi:10.1148/radiol.2362040166. 3. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. Am J Roentgenol. 2009;190:1163-1168. doi:10.2214/AJR.07.2799. 4. Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. 2008;249:16-31. doi:10.1148/radiol.2491070783. 5. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754-773. doi:10.1016/j.jacr.2010.06.013. 6. Casarella WJ. A patient’s viewpoint on a current controversy. Radiology. 2002;224(3):927. 7. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. There is considerable variability among radiologists in the management of incidental findings. A 2011 survey 7 conducted by Johnson et al found significant variability in how radiologists report and manage incidental findings. In a more recent survey2 of members of the American College of Radiology, 38% of respondents were aware of the guidance around incidental findings. Among respondents who were aware of the guidance, 89% replied that they were applying the recommendations in their practice. 1. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. 2. Berland LL, Silverman SG, Megibow AJ, Mayo-Smith WW. ACR members’ response to JACR white paper on management of incidental abdominal CT findings. J Am Coll Radiol. 2014;11:30-35. doi:10.1016/j.jacr.2013.06.002.


Appropriate follow-up imaging for incidental abdominal lesions for program(s): MSSP (MUC ID: X3759)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High value measure of potential imaging overuse.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriateness measure for follow-up imaging.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Incidental kidney, liver, and adrenal lesions are commonly found during abdominal imaging studies, with most of the findings being benign 1,2,3,4, 5. Given the low rate of malignancy, unnecessary follow-up procedures are costly and present a significant burden to patients1,6. To avoid excessive testing and costs, follow-up is not recommended for these small lesions. 1. Pickhardt PJ, Hanson ME, Vanness DJ, et al. Unexpected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology. 2008;249(1):151-159. doi:10.1148/radiol.2491072148. 2. Yee J, Kumar NN, Godara S, et al. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology. 2005;236:519-526. doi:10.1148/radiol.2362040166. 3. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. Am J Roentgenol. 2009;190:1163-1168. doi:10.2214/AJR.07.2799. 4. Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. 2008;249:16-31. doi:10.1148/radiol.2491070783. 5. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754-773. doi:10.1016/j.jacr.2010.06.013. 6. Casarella WJ. A patient’s viewpoint on a current controversy. Radiology. 2002;224(3):927. 7. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. There is considerable variability among radiologists in the management of incidental findings. A 2011 survey 7 conducted by Johnson et al found significant variability in how radiologists report and manage incidental findings. In a more recent survey2 of members of the American College of Radiology, 38% of respondents were aware of the guidance around incidental findings. Among respondents who were aware of the guidance, 89% replied that they were applying the recommendations in their practice. 1. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. 2. Berland LL, Silverman SG, Megibow AJ, Mayo-Smith WW. ACR members’ response to JACR white paper on management of incidental abdominal CT findings. J Am Coll Radiol. 2014;11:30-35. doi:10.1016/j.jacr.2013.06.002.


Appropriate follow-up imaging for incidental thyroid nodules in patients for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3763)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure, appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure, appropriate use measure. Incidental thyroid nodules are common and significant rarely; repeat imaging represents wasted resources.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Thyroid nodules are common, with estimates of prevalence as high as 50% 2. Desser and Kamaya3 found that the majority of incidentally noted thyroid nodules were benign with approximately 5% being malignant. Due to the common nature of small thyroid nodules combined with the low malignancy rate, additional follow-up is not recommended (ATA, 2009) 1. 1. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1-48. doi:10.1089/thy.2009.0110. 2. Mortensen JD, Woolner LB, Bennet WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab. 1955;15(10):1270-1280. doi:10.1210/jcem-15-10-1270. 3. Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimaging Clin N Am. 2008;18(3):463-478. doi:10.1016/j.nic.2008.03.005. 4. Ahmed S, Horton KM, Jeffrey RB Jr., Sheth S, Fishman EK. Incidental thyroid nodules on chest CT: review of the literature and management suggestions. Am J Roentgenol. 2010;195:1066-1071. doi:10.2214/AJR.10.4506. In their 2010 review4 of the literature, Ahmed et al concluded that there is significant inconsistency in how incidental thyroid nodules are reported and followed up by radiologists. Given the common nature of thyroid nodules, unnecessary follow-up of these nodules can result in excessive testing and costs for patients.


Appropriate follow-up imaging for incidental thyroid nodules in patients for program(s): MSSP (MUC ID: X3763)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure related to imaging overuse. It may be somewhat narrow for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Measure reflects potential overuse of follow-up imaging.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Thyroid nodules are common, with estimates of prevalence as high as 50% 2. Desser and Kamaya3 found that the majority of incidentally noted thyroid nodules were benign with approximately 5% being malignant. Due to the common nature of small thyroid nodules combined with the low malignancy rate, additional follow-up is not recommended (ATA, 2009) 1. 1. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1-48. doi:10.1089/thy.2009.0110. 2. Mortensen JD, Woolner LB, Bennet WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab. 1955;15(10):1270-1280. doi:10.1210/jcem-15-10-1270. 3. Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimaging Clin N Am. 2008;18(3):463-478. doi:10.1016/j.nic.2008.03.005. 4. Ahmed S, Horton KM, Jeffrey RB Jr., Sheth S, Fishman EK. Incidental thyroid nodules on chest CT: review of the literature and management suggestions. Am J Roentgenol. 2010;195:1066-1071. doi:10.2214/AJR.10.4506. In their 2010 review4 of the literature, Ahmed et al concluded that there is significant inconsistency in how incidental thyroid nodules are reported and followed up by radiologists. Given the common nature of thyroid nodules, unnecessary follow-up of these nodules can result in excessive testing and costs for patients.


Appropriate follow-up imaging for non-traumatic knee pain for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3802)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High value, appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority of making quality care more affordable by developing and spreading new health care delivery models.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Knee pain is common, affecting approximately 13.3% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for knee pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1.Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate follow-up imaging for non-traumatic knee pain for program(s): MSSP (MUC ID: X3802)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. Potentially inappropriate use of advanced imaging. Requires coordination and collaboration across system.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Imaging measure could be used across a range of programs.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Knee pain is common, affecting approximately 13.3% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for knee pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1.Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate use of imaging for non-traumatic shoulder pain for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3803)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? . Process measure; addresses NQS priority of making quality care more affordable by developing and spreading new health care delivery models.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Shoulder pain is common, affecting approximately 6.7% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate use of imaging for non-traumatic shoulder pain for program(s): MSSP (MUC ID: X3803)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. Potentially inappropriate use of advanced imaging. Requires coordination and collaboration across system.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Imaging measure could be used across a range of programs.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Shoulder pain is common, affecting approximately 6.7% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Assessment for Psoriatic Arthritis for program(s): MSSP (MUC ID: X3274)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Narrow topic area - better for clinicians/specialists.

Does the measure address a critical program objective as defined by MAP? No. Narrow topic area - better for clincians/specialists.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The prevalence of psoriatic arthritis (PsA) in the general population of the United States has been estimated to be between 0.1% to 0.25%. Among those with psoriasis, the prevalence of PsA is approximately 10%. This measure encourages dermatologists to actively seek signs and symptoms of PsA at each visit. Quick diagnosis of PsA leads to early treatment which alleviates signs and symptoms of PsA, prevents structural damage, and maximizes quality of life (QOL). As a result regular assessment or PsA which is the goal of this measure has a lot of potential for preventing negative outcomes, for reducing healthcare expenditure and improving outcomes.


Assessment for Psoriatic Arthritis for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3274)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement. 

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap for psoriasis and measure for dermatologists.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No. No testing data available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. This level of analysis is not indicated however, this measure can be applied at the clinican level to evaluate the number of screenings a physician rendered over a defined measurement time period.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The prevalence of psoriatic arthritis (PsA) in the general population of the United States has been estimated to be between 0.1% to 0.25%. Among those with psoriasis, the prevalence of PsA is approximately 10%. This measure encourages dermatologists to actively seek signs and symptoms of PsA at each visit. Quick diagnosis of PsA leads to early treatment which alleviates signs and symptoms of PsA, prevents structural damage, and maximizes quality of life (QOL). As a result regular assessment or PsA which is the goal of this measure has a lot of potential for preventing negative outcomes, for reducing healthcare expenditure and improving outcomes.


Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3783)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety measure for assessing potential overuse of medications. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Measure addresses patient safety.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired (or two part measure) that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III MOH criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose during the measurement period.


Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders for program(s): MSSP (MUC ID: X3783)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired (or two part measure) that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III MOH criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose during the measurement period.


Blood Pressure Screening by age 18 for program(s): MUEP (MUC ID: E1553)

Full Measure Specifications

NQF Number (if applicable): 1553

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: "CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented".

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure improtant for public reporting.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. The steward retired the non-eMEasure from NQF-endorsement because the measure was not being used.

Does the measure promote alignment and parsimony? No. This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: ?CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: High blood pressure (hypertension) is a growing concern for children and adolescents in the U.S. due mostly in part to a rapid increase in childhood obesity (Luma, 2006). A recent study of National Health and Nutrition Examination Survey data showed that, during 2003-2006, 2.6 percent of boys and 3.4 percent of girls age eight to 17 years had high blood pressure. Moreover, 13.6 percent of boys and 5.7 percent of girls in this age group had pre-high blood pressure. Overweight boys and obese boys and girls were significantly more likely to have these classifications (Ostchega Y, 2009). Autopsy reports of children and adolescents who have died unexpectedly have shown a positive and significant association with systolic and diastolic blood pressure and body mass index (BMI) (Hayman, 2003). Autopsy reports of adults with high levels of cholesterol and coronary heart disease showed that precursors to these diseases began in childhood (National Cholesterol Education Program). High blood pressure represents a significant financial burden, in 2006, the direct and indirect costs of high blood pressure were estimated at $63.5 billion overall (CDC, 2007). In addition to costs, resource utilization is also significantly higher among hypertensive people. Prescription medicines, inpatient visits, and outpatient visits constitute more than 90 percent of the overall incremental cost of treating hypertension (Balu, 2005). These costs can be expected to rise with increasing prevalence among children.


Blood Pressure Screening by age 18 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E1553)

Full Measure Specifications

NQF Number (if applicable): 1553

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: This measure applies only to 18 year olds - it is redundant with PQRS #317 "Preventive Care and Screening: Screening for High Blood Pressure and Follow up Documented" that captures all patients 18 years and above and includes a follow-up plan for abnormal results.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. During endorsement review the measure testing of record abstraction not as an eMeasure.  

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Measure is specified and tested for the appropriate setting and level of analysis.

Is the measure currently in use? No. Measure currently not in use.

Does the measure promote alignment and parsimony? No. This measure applies only to 18 year olds - it is redundant with PQRS #317  "Preventive Care and Screening: Screening for High Blood Pressure and Follow up Documented" that captures all patients 18 years and above and includes a follow-up plan for abnorma

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure was NQF-endorsed on August 15, 2011, however the steward opted to retire endorsement on August 27, 2014 due to low usage of measure.

Rationale for measure provided by HHS: High blood pressure (hypertension) is a growing concern for children and adolescents in the U.S. due mostly in part to a rapid increase in childhood obesity (Luma, 2006). A recent study of National Health and Nutrition Examination Survey data showed that, during 2003-2006, 2.6 percent of boys and 3.4 percent of girls age eight to 17 years had high blood pressure. Moreover, 13.6 percent of boys and 5.7 percent of girls in this age group had pre-high blood pressure. Overweight boys and obese boys and girls were significantly more likely to have these classifications (Ostchega Y, 2009). Autopsy reports of children and adolescents who have died unexpectedly have shown a positive and significant association with systolic and diastolic blood pressure and body mass index (BMI) (Hayman, 2003). Autopsy reports of adults with high levels of cholesterol and coronary heart disease showed that precursors to these diseases began in childhood (National Cholesterol Education Program). High blood pressure represents a significant financial burden, in 2006, the direct and indirect costs of high blood pressure were estimated at $63.5 billion overall (CDC, 2007). In addition to costs, resource utilization is also significantly higher among hypertensive people. Prescription medicines, inpatient visits, and outpatient visits constitute more than 90 percent of the overall incremental cost of treating hypertension (Balu, 2005). These costs can be expected to rise with increasing prevalence among children.


Breast Cancer Screening for program(s): MSSP (MUC ID: X3797)

Full Measure Specifications

NQF Number (if applicable): 2372

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: Endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines.

Does the measure address a critical program objective as defined by MAP? Yes. High priority risk assessment measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . Requires testing at clinician/ACO level

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Measure intended for use in multiple public and private sector programs.. Yes

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Breast cancer is the second most commonly diagnosed cancer among women (after skin cancer). After lung cancer, it causes more deaths in women than any other kind of cancer—there were nearly 40,000 estimated deaths from breast cancer in 2010. Deaths from breast cancer have decreased over the years, in part due to early detection using mammography. On average, mammography will detect about 80-90 percent of breast cancers in women without symptoms (American Cancer Society 2011). Based on evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality with higher benefit in older women (National Cancer Institute 2010). There is a demonstrated reduction in breast cancer mortality due to mammogram screening (National Business Group on Health 2011).


Breast Cancer Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3797)

Full Measure Specifications

NQF Number (if applicable): 2372

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines. Important for dual eligibles. Conditional on testing for reliability and validity at the clincian-level of analysis.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure strongly linked to outcomes.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Setting measure tested: Ambulatory

Is the measure currently in use? No. HEDIS health plan measure.

Does the measure promote alignment and parsimony? . This measure is used in comercial health plans in HEDIS. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Breast cancer is the second most commonly diagnosed cancer among women (after skin cancer). After lung cancer, it causes more deaths in women than any other kind of cancer—there were nearly 40,000 estimated deaths from breast cancer in 2010. Deaths from breast cancer have decreased over the years, in part due to early detection using mammography. On average, mammography will detect about 80-90 percent of breast cancers in women without symptoms (American Cancer Society 2011). Based on evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality with higher benefit in older women (National Cancer Institute 2010). There is a demonstrated reduction in breast cancer mortality due to mammogram screening (National Business Group on Health 2011).


Cellulitis Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0354)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measures are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measure required for VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf).  Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


Cervical Cancer Screening for program(s): MSSP (MUC ID: E0032)

Full Measure Specifications

NQF Number (if applicable): 0032

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: A good measure for ACOs in general, but not applicable to the Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Not apllicble to the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The measure has been tested and is in use for health plans.

Is the measure currently in use? Yes. HEDIS health plan measure.Finalized Public Programs: Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults;#Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Quality Reporting System (PQRS);#HRSAFederal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate: HEDIS; Wellpoint; Aetna; AmeriHealth Mercy Family of Companies; Cigna; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsement review - 2012.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Cervical cancer has a high survival rate when detected early, yet it is the second most common cancer among women worldwide (Myers et al. 2008). In the United States, about 12,000 women are diagnosed with cervical cancer each year. In 2010, more than 4,000 women died from cervical cancer (American Cancer Society 2010). For women in whom pre-cancerous lesions have been detected through Pap tests, the likelihood of survival is nearly 100 percent with appropriate evaluation, treatment and follow-up (American Cancer Society 2011). For women under 50 years old, cervical cancer is diagnosed in the early stage 61 percent of the time (American Cancer Society 2010). In 2008, the prevalence of recent Pap test use was lowest among older women, women with no health insurance and recent immigrants (American Cancer Society 2011).


Cervical Cancer Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0032)

Full Measure Specifications

NQF Number (if applicable): 0032

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure at the plan and system level.This is a population measure important to consumers is and consistent with the most recent guidelines. Important for dual eligibles. Conditional on successful testing for reliability and validity at the clinician level.

Does the measure address a critical program objective as defined by MAP? Yes. Population health measure meaningful to consumers.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No. Measure tested at health plan level.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. It is likely this measure can be applied at the clinician level.

Is the measure currently in use? Yes. Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults; Meaningful Use (EHR Incentive Program) - Eligible Professionals; Physician Quality Reporting System (PQRS); HRSA; HEDIS; Wellpoint; Aetna; AmeriHealth Mercy Family of Companies; Cigna; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No. This measure isaligned with new guidelines.

Does the measure promote alignment and parsimony? Yes. Is aligned with commercial health plan programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed this revised measure in 2012. The measure is consistent with the most recent guidelines.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Cervical cancer has a high survival rate when detected early, yet it is the second most common cancer among women worldwide (Myers et al. 2008). In the United States, about 12,000 women are diagnosed with cervical cancer each year. In 2010, more than 4,000 women died from cervical cancer (American Cancer Society 2010). For women in whom pre-cancerous lesions have been detected through Pap tests, the likelihood of survival is nearly 100 percent with appropriate evaluation, treatment and follow-up (American Cancer Society 2011). For women under 50 years old, cervical cancer is diagnosed in the early stage 61 percent of the time (American Cancer Society 2010). In 2008, the prevalence of recent Pap test use was lowest among older women, women with no health insurance and recent immigrants (American Cancer Society 2011).


Chronic Opioid Therapy Follow-up Evaluation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3775)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate follow-up for evaluation of opioid misuse. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of appriate assessment fo opioid misuse.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure is very similar to X3770 Overuse of Opioid Containing Medications for Primary Headache excpt that it applies to all patients on opioids regardless ofd9iagnosis.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence). In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence). In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence)


Chronic Opioid Therapy Follow-up Evaluation for program(s): MSSP (MUC ID: X3775)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence). In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence). In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence)


Clinical Outcome post Endovascular Stroke Treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3756)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is a high-value outcome measure for patients with stroke.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of those that suffered a stroke. (mRs=  0-2 is a good outcome).

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. /a

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The standard definition of a good clinical outcome from IA therapy is an mRS score of 0-2 at 90 days as assessed by a certified examiner independent of the interventional physician. This measures is supported by the multispecialty guidelines published in 2013 (1). 1. Sacks, D., C. M. Black, et al. (2013). "Multisociety Consensus Quality Improvement Guidelines for Intraarterial Catheter-directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology." Journal of vascular and interventional radiology : JVIR 24(2): 151-163.


Clinical Outcome post Endovascular Stroke Treatment for program(s): MSSP (MUC ID: X3756)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage further development

Preliminary analysis summary: Important patient-function measure after stroke treatment. Ideally, broader patient population would be preferable for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure reflects good patient function after stroke treatment.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The standard definition of a good clinical outcome from IA therapy is an mRS score of 0-2 at 90 days as assessed by a certified examiner independent of the interventional physician. This measures is supported by the multispecialty guidelines published in 2013 (1). 1. Sacks, D., C. M. Black, et al. (2013). "Multisociety Consensus Quality Improvement Guidelines for Intraarterial Catheter-directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology." Journal of vascular and interventional radiology : JVIR 24(2): 151-163.


Clinical Response to Oral Systemic or Biologic Medications for program(s): MSSP (MUC ID: X3726)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Important outcome measure for psoriasis. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: A significant proportion of psoriasis patients who are receiving treatment remain unsatisfied with their therapies due to various reasons including lack of or loss of efficacy, side effects, and inconvenience, among others. Treatment dissatisfaction also contributes to patients discontinuing therapy. This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.


Clinical Response to Oral Systemic or Biologic Medications for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3726)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Outcome measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement. 

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome; fills a gap for dermatologists

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Adds measures for dermatologists

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: A significant proportion of psoriasis patients who are receiving treatment remain unsatisfied with their therapies due to various reasons including lack of or loss of efficacy, side effects, and inconvenience, among others. Treatment dissatisfaction also contributes to patients discontinuing therapy. This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): MUEP (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination measure specific for EHRs that uses Clinical Document Architecture (CDA) that specifies how critical data elements should be encoded for exchange and interoperability.

Does the measure address a critical program objective as defined by MAP? Yes. High-value care coordination measure that uses EHR-specific Clinical Data Architecture (CDA) format for interoperability.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): MSSP (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination is a priority for Medicare patients and a good assement of an ACO.

Does the measure address a critical program objective as defined by MAP? Yes. Care coodination is important for Medicare patients.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Specialist Report Sent to Primary Care Physician for program(s): MSSP (MUC ID: X3302)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination across providers is a critical program objective.

Does the measure address a critical program objective as defined by MAP? Yes. High priority measure focused on care coordination.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? New eMeasure. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3780)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use for lab tests in the ED.

Does the measure address a critical program objective as defined by MAP? Yes. Assesses broad population; addressed NQS priority of providing better and effective treatment; process measure

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient.


Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding for program(s): MSSP (MUC ID: X3780)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Appropriate use measure.  

Does the measure address a critical program objective as defined by MAP? No. Overuse of uncessary coagulation studies is prevalent.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The Medicare Annual Wellness Visit specifies "detection of any cognitive impairment". Although the USPSTF stated that the evidence is insufficient to recommend screening for cognitive impairment in asymptomatic population though age 80 years and above were not specifically addressed. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Cognitive impairmnet is an important condition for Medicare.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. No assessment of alignment in the context of the PQRS-based programs due to lack of testing data and performance information however, this measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): MUEP (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): MSSP (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Dementia is a high priority area for Medicare. Results of cognitive assessment will be captured in EHR. Need to consider insufficient rating from USPSTF due to lack of evidence that early screening or intervention improves outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of health risk for elderly.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Communication and shared decision-making with patients and families for interventional oncology procedures for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3735)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination and patient-centered measure. A patient-reported outcome measure to assess the patient or family's perspective of the discussion would be of higher value than a documentation measure.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination and patient-centered measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. No level of analysis identified, however this measure can be applied at the clinican level to account for the number of physicians who provide documentation of discussing the procedure with their patients' families.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: As with any cancer therapy, patients and family members may misunderstand or not know the intent of an interventional oncologic procedure. This measure aims to enhance the patient experience with health care by increasing patient and family understanding of their care and to promote an environment of shared decision-making. The American Society of Clinical Oncology has a similar practice guideline for medical oncologists providing chemotherapy.


Communication and shared decision-making with patients and families for interventional oncology procedures for program(s): MSSP (MUC ID: X3735)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Reflects shared decisionmaking for medically complex patients. Optimally would include patient voice.

Does the measure address a critical program objective as defined by MAP? Yes. Reflects shared decisionmaking in oncology.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: As with any cancer therapy, patients and family members may misunderstand or not know the intent of an interventional oncologic procedure. This measure aims to enhance the patient experience with health care by increasing patient and family understanding of their care and to promote an environment of shared decision-making. The American Society of Clinical Oncology has a similar practice guideline for medical oncologists providing chemotherapy.


Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3751)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in speciality care measurement.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Currently being specified and tested.

Is the measure currently in use? No. Not currently in use in other programs.

Does the measure promote alignment and parsimony? Yes. This measure would promote alignment by encouraging specality providers to participate in reporting for the programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Implementing this quality measure will lead to a more complete pre-operative evaluation of pelvic organ prolapse (POP) which will result in: 1) more appropriate surgery performed with better surgical outcomes, lower recurrence rates, and fewer re-operations for POP, 2) prevention of unnecessary surgery and 3) improved ability to assess surgical outcomes over time. Reoperation rates for recurrent POP have been shown to be as high as 30%. It is self-evident that if one does not identify a defect in a specific compartment, one is unlikely to correct it. Failure to identify the full extent of POP at the time of initial surgery has been implicated as a significant cause of repeat surgery for POP, as recurrence following the initial surgery commonly occurs early in the post-operative period and often involves a different compartment than that addressed during the initial surgery. ACOG guidelines recommend that when POP surgery is performed defects in all compartments should be addressed using a standardized reproducible exam. Anger et al proposed a series of quality indicators (QI’s) for the purpose of measuring and comparing the care provided to women with prolapse in different clinical settings. The QI’s were based on the Assessing the Care of Vulnerable Elders (ACOVE) project and evaluated using the “RAND Appropriateness Method”. One of the QI’s identified and validated by the panel was: a standardized exam for POP using the Pelvic Organ Prolapse Quantification scale (POP-Q) should be conducted and the prolapse stage of each compartment documented prior to undertaking surgical intervention to correct pelvic organ prolapse. The authors affirmed that objective standardized assessment of vaginal prolapse pre-operatively ensures that the selected procedure is the most appropriate. In addition the POP-Q provides a means of assessing surgical outcomes. Finally, the panel concluded that woman with asymptomatic POP of stage 1 or less should not be offered surgical intervention. The final QI was determined to prevent physicians from offering surgical therapy to women with no indication for surgery. The assignment of Stage 1 prolapse is predicated on conducting an objective standardized exam for vaginal prolapse. (POPQ). In a recent study we found that 67.6% (431/638) of women had a Baden Walker or POP-Q prior to the exam and that 91% of high volume surgeons vs 41% of low volume surgeons completed either a POP-Q or a Baden-Walker formal evaluation of pelvic organ prolapse prior to surgery.


Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair for program(s): MSSP (MUC ID: X3751)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Implementing this quality measure will lead to a more complete pre-operative evaluation of pelvic organ prolapse (POP) which will result in: 1) more appropriate surgery performed with better surgical outcomes, lower recurrence rates, and fewer re-operations for POP, 2) prevention of unnecessary surgery and 3) improved ability to assess surgical outcomes over time. Reoperation rates for recurrent POP have been shown to be as high as 30%. It is self-evident that if one does not identify a defect in a specific compartment, one is unlikely to correct it. Failure to identify the full extent of POP at the time of initial surgery has been implicated as a significant cause of repeat surgery for POP, as recurrence following the initial surgery commonly occurs early in the post-operative period and often involves a different compartment than that addressed during the initial surgery. ACOG guidelines recommend that when POP surgery is performed defects in all compartments should be addressed using a standardized reproducible exam. Anger et al proposed a series of quality indicators (QI’s) for the purpose of measuring and comparing the care provided to women with prolapse in different clinical settings. The QI’s were based on the Assessing the Care of Vulnerable Elders (ACOVE) project and evaluated using the “RAND Appropriateness Method”. One of the QI’s identified and validated by the panel was: a standardized exam for POP using the Pelvic Organ Prolapse Quantification scale (POP-Q) should be conducted and the prolapse stage of each compartment documented prior to undertaking surgical intervention to correct pelvic organ prolapse. The authors affirmed that objective standardized assessment of vaginal prolapse pre-operatively ensures that the selected procedure is the most appropriate. In addition the POP-Q provides a means of assessing surgical outcomes. Finally, the panel concluded that woman with asymptomatic POP of stage 1 or less should not be offered surgical intervention. The final QI was determined to prevent physicians from offering surgical therapy to women with no indication for surgery. The assignment of Stage 1 prolapse is predicated on conducting an objective standardized exam for vaginal prolapse. (POPQ). In a recent study we found that 67.6% (431/638) of women had a Baden Walker or POP-Q prior to the exam and that 91% of high volume surgeons vs 41% of low volume surgeons completed either a POP-Q or a Baden-Walker formal evaluation of pelvic organ prolapse prior to surgery.


Comprehensive Diabetes Care: Eye Exam for program(s): MSSP (MUC ID: E0055)

Full Measure Specifications

NQF Number (if applicable): 0055

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure for diabetes; requires coordination to ensure care delivery and documentation.

Does the measure address a critical program objective as defined by MAP? Yes. Measure requires coordination of care and results to ensure receipt of eye care within ACO.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Finalized Public Programs: Dual Eligibles Core Quality Measures- Captiated Demonstrations;#Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Medicare Part C Plan Rating;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: at least 1 Beacon community; HEDIS; Wellpoint; Aetna; Cigna; Alliance for Health; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure widely used in public and private applications..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Clinically important area for at risk population and aligns with PQRS and MU


Consideration of Non-Pharmacologic Interventions for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3776)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of providing alternative treatment to opioids for pain management. Important for dual eligibles. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority that focuses on promoting the most effective prevention and treatment.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non opioid therapies (strong recommendation, moderate-quality evidence)


Consideration of Non-Pharmacologic Interventions for program(s): MSSP (MUC ID: X3776)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to alternatives to chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non opioid therapies (strong recommendation, moderate-quality evidence)


Controlling High Blood Pressure for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3792)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on testing for reliability and validity at the clinician-level and review by NQF pending final hypertension guidelines from ACC due in 2015.

Does the measure address a critical program objective as defined by MAP? Yes. Intermediate outcome measure for a prevalent condition.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. HEDIS measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. Inclusion in the PQRS program could promote alignment with the two other programs the measure is currently active in. Inclusion in multiple programs could  enhance the measure's performance and efficiency.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Hypertension is a very significant health issue in the United States. Nearly 78 million adults have high blood pressure. Yet, only fifty three percent of adults with hypertension have their blood pressure under control. The United States spends over $46 billion annually in direct and indirect costs due to high blood pressure. (Go AS, Mozaffarian D, Roger VL et al. 2014) Uncontrolled hypertension can lead to serious complications such as coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease and retinopathy. Among adults with diagnosed diabetes, 71 percent also have hypertension (CDC 2014). Uncontrolled hypertension places adults with diabetes at a higher risk of developing serious complications. Controlling blood pressure has been shown to reduce the probability of undesirable and costly outcomes. The relationship between the measure (control of hypertension) and the long-term clinical outcomes is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke, heart failure, coronary heart disease, diabetes complications and overall mortality (Eighth Joint National Committee).


Controlling High Blood Pressure for program(s): MSSP (MUC ID: X3792)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on review by NQF pending final hypertension guidelines from ACC due in 2015. Existing BP control measure already in MSSP program.

Does the measure address a critical program objective as defined by MAP? Yes. Blood pressure control is a high priority issue for Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Needs testing at clinician/ACO level,

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Hypertension is a very significant health issue in the United States. Nearly 78 million adults have high blood pressure. Yet, only fifty three percent of adults with hypertension have their blood pressure under control. The United States spends over $46 billion annually in direct and indirect costs due to high blood pressure. (Go AS, Mozaffarian D, Roger VL et al. 2014) Uncontrolled hypertension can lead to serious complications such as coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease and retinopathy. Among adults with diagnosed diabetes, 71 percent also have hypertension (CDC 2014). Uncontrolled hypertension places adults with diabetes at a higher risk of developing serious complications. Controlling blood pressure has been shown to reduce the probability of undesirable and costly outcomes. The relationship between the measure (control of hypertension) and the long-term clinical outcomes is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke, heart failure, coronary heart disease, diabetes complications and overall mortality (Eighth Joint National Committee).


Coordinating Care - Emergency Department Referrals for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coodination measure of ED provider attempting to contact patient's primary care provider or specialist after a patient is seen with with asthma or chest pain.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination - emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department.?

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Emergency Department Referrals for program(s): MUEP (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Emergency Department Referrals for program(s): MSSP (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions. Encourage harmonization with PCPI regarding transition record measure.

Does the measure address a critical program objective as defined by MAP? Yes. Ensures care coordination across multiple settings.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination measure of follow-up within 72 hours after an ED visit for asthma or chest pain.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination -  a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department.?

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): MUEP (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): MSSP (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions

Does the measure address a critical program objective as defined by MAP? Yes. Ensures care coordination across multiple settings.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coronary Artery Disease (CAD): Antiplatelet Therapy for program(s): MSSP (MUC ID: E0067)

Full Measure Specifications

NQF Number (if applicable): 0067

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Optimal Vascular Care measure (E0076) contains this measure as a component of the composite. Both measures would be redundant.

Does the measure address a critical program objective as defined by MAP? Yes. Heart disease is a prevalent condition for Medicare.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Yes. Measure is in PQRS.Finalized Public Programs: Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: AmeriHealth Mercy Family of Companies

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?This measure is a compnent of the OPtimal Vascular Care measure. Both measures would be redundant..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Clinically important area and aligns with PQRS


Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) for program(s): MSSP (MUC ID: E0070)

Full Measure Specifications

NQF Number (if applicable): 0070

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinical measure that does not reflect MSSP program objectives. Beta blocker persistence ( NQF #71) measure may better reflect care across continuum.

Does the measure address a critical program objective as defined by MAP? No. Important clinical measure for CAD, though does not reflect MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: AmeriHealth Mercy Family of Companies

Does a review of its performance history raise any concerns? Yes. Need current level of performance to assess whether measure is topped out.

Does the measure promote alignment and parsimony? Measure included in multiple programs.. Yes

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Clinically important area for at risk populations.


Coronary Artery Disease (CAD): Symptom Management: for program(s): MSSP (MUC ID: X1033)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure assesses patient-reported activity and management. Conditional support pending submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. CAD very prevalent in Medicare population. Measure assesses patient-reported activity and management.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Clinically important topic and aligns with PQRS


Depression Remission at Six Months for program(s): MSSP (MUC ID: E0711)

Full Measure Specifications

NQF Number (if applicable): 0711

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Support a depression outcome measure for MSSP. Should align with other federal programs. PQRS measure focused on 12 month remission. Recommend pairing with measure 0712 Use of PHQ9.

Does the measure address a critical program objective as defined by MAP? Yes. High-value outcome measure for depression - prevalent in the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Minnesolta Community Measurement: state-wide measure results improved from 5.2% (2009) to 6.9% in 2013.Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Shared Savings ProgramPrivate: MN Community Msmt

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?Outcome measure. The related Depression Remission at 12 months measure is finalized in PQRS..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Patient -reported outcome performance measure (PRO-PM). NQF also endorsed the Depression Remission at 12 months.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The Centers for Disease Control and Prevention states that nationally 15.7% of people report being told by a health care professional that they had depression at some point in their lifetime. Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily. According to National Institute of Mental Health (NIMH), 6.7 percent of the U.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 - 44. Additionally, dysthymia accounts for an additional 3.3 million Americans.


Depression Utilization of the PHQ-9 Tool for program(s): MSSP (MUC ID: E0712)

Full Measure Specifications

NQF Number (if applicable): 0712

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure intended to be paired with one of two outcome measures - Depression Remission at 6 month and Depresion Remission at 12 months; condiitonal on pairing with either or both outcome measures.

Does the measure address a critical program objective as defined by MAP? Yes. Monitoring tool for patients with depression- a condition prevalent in the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Yes. Minnesota Health Scores - Overall rate is 70% for groups/practices.Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: MN Community Msmt

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Only if paired with the outcome measure..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Paired with two outcome measures - Depression Remission at 6 months and Depression Remission at 12 months.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Process measure, administration of the PHQ-9 tool, that is paired with and supports the outcome measures of remission and response


Diabetes: Foot exam for program(s): MSSP (MUC ID: E0056)

Full Measure Specifications

NQF Number (if applicable): 0056

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Diabetes process measure that does not reflect care across continuum or coordination of services.

Does the measure address a critical program objective as defined by MAP? No. Diabetes process measure. Does not reflect program objectives. .

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: at least one Beacon community; HEDIS; Wellpoint

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure finalized in multiple programs.. Yes

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Clinically important area for at risk population and aligns with PQRS and MU


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): MUEP (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient safety eMeasure. Concerns about overtreatment in the elderly resulting in hypoglycemic events are focused on patients aged 75 years and older with comorbidities and cognitive impairment. Important for dual eligibles. Conditional on NQF review and further consideration of evidence for age specifications.

Does the measure address a critical program objective as defined by MAP? Yes. HIgh-value intermediate outcome, patient safety eMeasure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data found.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): MSSP (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Submission to NQF for review. Age cut-off at 65 years needs further review (highly dependent on functional status and related co-morbidities)

Does the measure address a critical program objective as defined by MAP? Yes. Overtreatment and resultant harm is a high priority for Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Overuse is a high priority area of measurement across multiple programs. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination for a condition important in Medicare. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): MUEP (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): MSSP (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Healthcare proxy requires coordination across providers. High priority area for Medicare and MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Dementia is a high priority condition for Medicare frequently requiring coordination across providers.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of Signed Opioid Treatment Agreement for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3777)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Limited evidence on effectiveness but recommended by multiple societies. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority that focuses on promoting the most effective prevention and treatment.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COT should include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low-quality evidence). Clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient education (weak recommendation, low-quality evidence)


Documentation of Signed Opioid Treatment Agreement for program(s): MSSP (MUC ID: X3777)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COT should include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low-quality evidence). Clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient education (weak recommendation, low-quality evidence)


Door to puncture time for endovascular stroke treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3747)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: In 2011, the Brain Attack Coalition proposed door-to-treatment times of 2 hours as a benchmark for patients undergoing [endovascular] intra-arterial therapy. Shorter D2P result in better outcomes. Only 52% of all patients in a multicenter registry achieved the targeted D2P time of 2 hours.

Does the measure address a critical program objective as defined by MAP? Yes. This measure is siilar to the door-to balloon time for AMI. Time to treatment is related to patient outcomes.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. This measure would promote alignment as it addresses a specality area of care.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Acknowledgment of the critical importance of time to reperfusion for obtaining favorable outcomes in myocardial reperfusion treatments has led to the formation of initiatives such as Door to Balloon. The impressive results in shortening the time to myocardial reperfusion for acute MI obtained by such initiatives provided an impetus for launching similar initiatives related to IV tPA for stroke. This measures is supported by the multispecialty guidelines published in 2013 (1). 1. Sacks, D., C. M. Black, et al. (2013). "Multisociety Consensus Quality Improvement Guidelines for Intraarterial Catheter-directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology."Journal of vascular and interventional radiology : JVIR 24(2): 151-163.


Door to puncture time for endovascular stroke treatment [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3747)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This intermediate clinical timeliness of appropriate stroke treatment outcome measure is important for a leading cause of mortality and disability for the Medicare fee-for-service population. The measure promotes alignment across the PQRS-based programs.

Does the measure address a critical program objective as defined by MAP? Yes. This measure focuses on important intermediate health outcomes that will improve the quality of stroke treatment for the Medicare FFS population.·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: Neurologic conditions and injuries are important clinical conditions that affect millions of Americans each year. Strokes are the fourth leading cause of death in the US and a leading cost of disability. With over 795,000 people suffering from a stroke each year, this is an important measurement areas for the Medicare Fee-For-Service population.[i],[ii],[iii] ·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response:  This measure focus does focus on important intermediate health outcomes that will improve the quality of stroke treatment for the Medicare FFS population. This measure does not directly improve the rate of growth in healthcare spending. ·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response:  This measure is limited to the door to puncture time within an acute hospitalization, thus has limited applicability across care settings.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response:  This measure is under consideration for all of the PQRS-based programs. ·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This is an important intermediate clinical outcome measure for a significant number of Medicare beneficiaries but does not address the high-value measurement areas identified by the MAP.[i] Centers for Disease Control. Available at www.cdc.gov/nchs/fastats/stroke.htm. American Stroke Association. Available at www.strokeassociation.org/STROKEORG/AboutStroke/About-Stroke_UCM_308529_SubHomePage.jsp. Last accessed February 2012.[ii] The Internet Stroke Center. Available at www.strokecenter.org/patients/about-stroke/stroke-statistics/. Last accessed February 2012.[iii] American Stroke Association. Available at www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? Yes. This intermediate clinical outcome measure is important for a leading cause of mortality and disability for the Medicare fee-for-service population. The measure also promotes alignment across the PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Acknowledgment of the critical importance of time to reperfusion for obtaining favorable outcomes in myocardial reperfusion treatments has led to the formation of initiatives such as Door to Balloon. The impressive results in shortening the time to myocardial reperfusion for acute MI obtained by such initiatives provided an impetus for launching similar initiatives related to IV tPA for stroke. This measures is supported by the multispecialty guidelines published in 2013 (1). 1. Sacks, D., C. M. Black, et al. (2013). "Multisociety Consensus Quality Improvement Guidelines for Intraarterial Catheter-directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology."Journal of vascular and interventional radiology : JVIR 24(2): 151-163.


Evaluation or Interview for Risk of Opioid Misuse for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3774)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety measure screening for opioid misuse in all patients regardless of diagnosis.  Priority for dual eligibles. Conditional on submitting to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety measure screening for risk of opioid miuse.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.  This measure applies to a broader population than MUC X3770.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low-quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low-quality evidence). A benefit-to-harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low-quality evidence)


Evaluation or Interview for Risk of Opioid Misuse for program(s): MSSP (MUC ID: X3774)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support.

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low-quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low-quality evidence). A benefit-to-harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low-quality evidence)


Extravasation of contrast following contrast-enhanced computed tomography (CT) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3523)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value adverse outcome and patient safety measure.

Does the measure address a critical program objective as defined by MAP? Yes. High-value adverse outcome and patient safety measure. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Extravasation of contrast leads to a local inflammatory response that can, in turn, cause acute tissue injury. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases. Extravasation is a relatively common occurrence that affects 1 out of 147 patients who are given intravenous contrast. Elderly patients and small children, as well as patients with limited communication abilities, severe illness or debilitation, or abnormal circulation, are at increased risk for extravasation. 1. American College of Radiology Committee on Drugs and Contrast Media. ACR manual on contrast media- Version 9. 2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69657 intravenous injections. Radiology. 2007;243(1):80-87. doi:10.1148/radiol.2431060554.


Extravasation of contrast following contrast-enhanced computed tomography (CT) for program(s): MSSP (MUC ID: X3523)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important adverse event for hospital setting; may not add value for ACO.

Does the measure address a critical program objective as defined by MAP? Yes. High risk adverse outcome for elderly

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Extravasation of contrast leads to a local inflammatory response that can, in turn, cause acute tissue injury. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases. Extravasation is a relatively common occurrence that affects 1 out of 147 patients who are given intravenous contrast. Elderly patients and small children, as well as patients with limited communication abilities, severe illness or debilitation, or abnormal circulation, are at increased risk for extravasation. 1. American College of Radiology Committee on Drugs and Contrast Media. ACR manual on contrast media- Version 9. 2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69657 intravenous injections. Radiology. 2007;243(1):80-87. doi:10.1148/radiol.2431060554.


Frequency of inadequate bowel preparation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3760)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patients captured in this measure represent wasted resources.

Does the measure address a critical program objective as defined by MAP? . Patients captured in this measure represent wasted resources.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Poor bowel preparation is a major impediment to the effectiveness of colonoscopy, affecting the ability to detect polyps and influencing the timing of repeat examinations. Given the increased premalignant potential of advanced adenomas, suboptimal bowel preparation may cause an unacceptably high failure rate at identifying these important lesions, thereby compromising the effectiveness of the colonoscopy. Adenoma miss rates in the context of suboptimal bowel preparation are as high as 42%. Poor bowel preparation influences the timing of repeat examination with practitioners recommending follow-up examinations earlier than standard intervals due to inadequate bowel preparation. The economic burden of repeating examinations because of inadequate bowel preparation is substantial. This leads our societies to recommend this measure so individual practitioners can monitor their percentages of examinations requiring repeat because of preparation and compare their percentages to others. We believe that adherence to this measure will result in a reduction of duplicative or unnecessary tests and, therefore, savings to the Medicare program.


Frequency of inadequate bowel preparation for program(s): MSSP (MUC ID: X3760)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure regarding colonoscopy preparation. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Inadequate preparation may reflect lack of coordination and patient-centered instructions.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Poor bowel preparation is a major impediment to the effectiveness of colonoscopy, affecting the ability to detect polyps and influencing the timing of repeat examinations. Given the increased premalignant potential of advanced adenomas, suboptimal bowel preparation may cause an unacceptably high failure rate at identifying these important lesions, thereby compromising the effectiveness of the colonoscopy. Adenoma miss rates in the context of suboptimal bowel preparation are as high as 42%. Poor bowel preparation influences the timing of repeat examination with practitioners recommending follow-up examinations earlier than standard intervals due to inadequate bowel preparation. The economic burden of repeating examinations because of inadequate bowel preparation is substantial. This leads our societies to recommend this measure so individual practitioners can monitor their percentages of examinations requiring repeat because of preparation and compare their percentages to others. We believe that adherence to this measure will result in a reduction of duplicative or unnecessary tests and, therefore, savings to the Medicare program.


Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure for program(s): MSSP (MUC ID: X3481)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures such as patient-reported outcomes in the area of functional status measures. However, this measure needs further development and testing to be ready for implementation.

Does the measure address a critical program objective as defined by MAP? No. This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. New measureFinalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Goal-setting addresses patient engagement, a high priority of the National Quality Strategy and CMS. Only 4 of 64 measures in the 2014 measure set address this domain. Evidence suggests that physicians rarely conduct functional status assessments for patients with congestive heart failure.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): MSSP (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Meets program objectives. Could be appropriate PROM for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Functional status assessment for chronic pain would meet program objectives.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Patient-reported outcome measure could be used across settings and programs.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Support development as a functional patient-reported outcome eMeasure, not just  "score from one of a select list of pain interference assessment tools was recorded at least twice".  A PRO of improvement in pain associated with osteoarthritis fills a needed gap in PROs and functional status measures.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap area in its' assessment of chronic pain due to oseteoarthritis . It is not, however, a functional outcome measure because it only specifies "score from one of a select list of pain interference assessment tools was recorded at le

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. No testing data available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): MUEP (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS eMeasure.

Does the measure address a critical program objective as defined by MAP? .

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): MSSP (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. High-value patient-reported outcome measure for procedure frequently done in the Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? High value measure could be used across multiple programs.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): MUEP (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value, patient-reported functional outcome eMeasure.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, patient-reported functional outcome measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? No. No program use information provided.

Does the measure promote alignment and parsimony? . This measure could be adapted to be included in the EHR Incentive Program since the data collected is derived from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): MSSP (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. High-value patient-reported outcome measure for procedure frequently done in the Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient-reported functional outcome eMeasure.

Does the measure address a critical program objective as defined by MAP? . This is a high-value, patient-reported outcome measure that is important to consumers.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? Yes. This measure is being used by the Veterans Health Administration.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. This measure is currently in use by the Veterans Health Administration and could be adapted to be included in the EHR Incentive Program since the data collected is derived from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): MUEP (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0355)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Cost measures are required for VBPM. Quality measures are needed for GI hemorrhage to match with the cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L.  Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


Gout: Serum Urate Monitoring for program(s): MSSP (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: NQF did not approve this eMeasure for trial Use due to lack of evidence of relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? No. Very narrow topic area.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Serum Urate Monitoring for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: NQF did not approve this eMeasure for Trial Use due to lack of evidence of relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. New eMeasure submitted to NQF for approval for Trial Use.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Submitted to NQF for possible approval as an eMeasure for Trial Use, i.e., eMeasure that have not been tested in the field but otherwise seem like good measures.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. Measure specified for the clinician level of analysis.

Is the measure currently in use? No. Untested eMeasure considered by NQF for Trial Use.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure was reviewed by NQF and not approved for eMeasure Trial Use.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Serum Urate Monitoring for program(s): MUEP (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. New eMEasure submitted to NQF for approval for eMeasure Trial Use in 2014.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. CMS indicates that all EHR measures are being respecified using most recent standards.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Adds measures in a new topic area.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): MSSP (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important clinician measure in gap area. New eMeasure to be tested. Not appropriate for MSSP program.

Does the measure address a critical program objective as defined by MAP? No. Does not meet MSSP objectives. Narrow clinical area.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure approved for trial use.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is the first measure for gout - a condition affecting more than 8 million Americans and affects African Americn men three times more than white men. Important for dual eligibles. NQF-approved eMeasure for Trial Use.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap - there are no other measure for gout.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. NQF-approved eMeasure for Trial Use - no testing yet.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. The measure is specified for the clinician level of analysis.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure could be included in both the PQRS and the EHR Incentive Program since the data collected are dervied from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure has received preliminary approval for " eMeasure Trial-Use" implementaion. Upon receipt of testing data, NQF will re-evaluate this measure for full endorsement.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): MUEP (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: NQF approved this eMeasure for Trial Use in 2014. Aligns wirth PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Submitted to NQF for approval for eMeasure Trial Use in 2014.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure for Trial Use have not been tested in the field.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF approved this eMeasure for Trial Use in 2014.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): MSSP (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Health risk screening with follow-up. Could possibly be combined with isolated screening measure (x3512). Most appropriate for duals population.

Does the measure address a critical program objective as defined by MAP? Yes. Health risk assessment with follow-up intervention. Potentially limited applicability to Medicare FFS (except duals).

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process eMeasure of appropriate treatment after a positive HCV screeening test. Suggest combining or pairing with X3512.

Does the measure address a critical program objective as defined by MAP? Yes. Positive screening follow-up measure for Hepatitis C.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. The eMeasure and Health e-Decisions clinical support rules are under development under HHS funding.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): MUEP (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): MSSP (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen.

Does the measure address a critical program objective as defined by MAP? No. Screening measure for population health, though not as relevant to Medicare FFS population. Does not require follow-up intervention if positive.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): MUEP (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: A?ligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Population health screening measure aligned with CDC recommendations.

Does the measure address a critical program objective as defined by MAP? Yes. Population health screening for Hepatitis C consistent with CDC recommendations.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. Under development.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hip Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0356)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Though surgery measures are finalized in PQRS, additional quality measures specific to hip replacedment are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


HIV medical visit frequency for program(s): MSSP (MUC ID: E2079)

Full Measure Specifications

NQF Number (if applicable): 2079

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression)

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? Yes. Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Finalized for PQRS, though low HIV prevalence in broad Medicare FFS population..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Retention is a critical component of the HIV care continuum. Although HIV viral suppression is the ultimate outcome of HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap-around supportive services within HIV care.


HIV Screening of STI patients for program(s): MSSP (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important population health measure for general population.

Does the measure address a critical program objective as defined by MAP? No. Low prevalence for Medicare population. Could be appropriate for duals population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Screening of STI patients for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure overlaps somewhat with X3299 HIV:Ever screened for HIV. This measure, however, focuses on testing at a time of known high-risk as compared to population-based screening. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. High-risk population screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Testing is not yet complete. Testing in a group of community health centers that use a commen, certified EHR is forthcoming.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure overlaps somewhat with X3299 HIV:Ever screened for HIV. This measure, however, focuses on testing at a time of known high-risk as compared to population=based screening.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Screening of STI patients for program(s): MUEP (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. High-risk, population screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Viral Load Suppression for program(s): MSSP (MUC ID: E2082)

Full Measure Specifications

NQF Number (if applicable): 2082

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. This intermediate outcome measure preferred to HIV process measures.

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Finalized Public Programs: Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure in use across multiple federal programs.. Yes

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Viral load suppression is a critical component of the HIV care continuum and the ultimate outcome of HIV care/treatment. 1. HIV Trialists´ Collaborative Group. Zidovudine, didanosine, and zalcitabine in the treatment of HIV infection: meta-analyses of the randomized evidence. Lancet. Jun 12 1999; 353(9169):2014-2025. 2. Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team. N Engl J Med. Sep 11 1997; 337(11):725-733. 3. Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009; 4(5):e5575. 4. Mocroft A, Vella S, Benfield TL, et al. Changing patterns of mortality across Europe in patients infected with HIV-1. EuroS IDA Study Group. Lancet. Nov 28 1998; 352(9142):1725-1730. 5. Hogg RS, Yip B, Chan KJ, et al. Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA. Nov 28 2001; 286(20):2568-2577. 6. Sterne JA, May M, Costagliola D, et al. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet. Apr 18 2009; 373(9672):1352-1363. 7. Baker JV, Peng G, Rapkin J, et al. CD4+ count and risk of non-AIDS diseases following initial treatment for HIV infection. AIDS. Apr 23 2008; 22(7):841-848. 8. Palella FJ, Jr., Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med. Apr 15 2003; 138(8):620-626. 9. Cain LE, Logan R, Robins JM, et al. When to initiate combined antiretroviral therapy to reduce mortality and AIDS-defining illness in HIV-infected persons in developed countries: an observational study. Ann Intern Med. Apr 19 2011; 154(8):509-515. 10. Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. Jul 15 2010; 363(3):257-265. 11. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009; 360(18):1815-1826. 12. Writing Committee of the CASCADE Collaboration. Timing of HAART initiation and clinical outcomes in human immunodeficiency virus type 1 seroconverters. Arch Intern Med. Sep 26 2011; 171(17):1560-1569. 13. Atta MG, Gallant JE, Rahman MH, et al. Antiretroviral therapy in the treatment of HIV-associated nephropathy. Nephrol Dial Transplant. Oct 2006; 21(10):2809-2813. 14. Schwartz EJ, Szczech LA, Ross MJ, Klotman ME, Winston JA, Klotman PE. Highly active antiretroviral therapy and the epidemic of HIV+ end-stage renal disease. J Am Soc Nephrol. Aug 2005; 16(8):2412-2420. 15. Kalayjian RC, Franceschini N, Gupta SK, et al. Suppression of HIV-1 replication by antiretroviral therapy improves renal function in persons with low CD4 cell counts and chronic kidney disease. AIDS. Feb 19 2008; 22(4):481-487. 16. Calmy A, Gayet-Ageron A, Montecucco F, et al. HIV increases markers of cardiovascular risk: results from a randomized, treatment interruption trial. AIDS. May 15 2009; 23(8):929-939. 17. Kuller LH, Tracy R, Belloso W, et al. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. PLoS Med. Oct 21 2008; 5(10):e203. 18. Torriani FJ, Komarow L, Parker RA, et al. Endothelial function in human immunodeficiency virus-infected antiretroviral naive subjects before and after starting potent antiretroviral therapy: The ACTG (AIDS Clinical Trials Group) Study 5152s. J Am Coll Cardiol. Aug 12 2008; 52(7):569-576. 19. Mellors JW, Rinaldo CR, Jr., Gupta P, White RM, Todd JA, Kingsley LA. Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science. May 24 1996; 272(5265):1167-1170. 20. Vlahov D, Graham N, Hoover D, et al. Prognostic indicators for AIDS and infectious disease death in HIV-infected injection drug users: plasma viral load and CD4+ cell count. JAMA. Jan 7 1998; 279(1):35-40. 21. Anastos K, Kalish LA, Hessol N, et al. The relative value of CD4 cell count and quantitative HIV-1 RNA in predicting survival in HIV-1-infected women: results of the women´s interagency HIV study. AIDS. Sep 10 1999; 13(13):1717-1726. 22. O´Brien TR, Blattner WA, Waters D, et al. Serum HIV-1 RNA levels and time to development of AIDS in the Multicenter Hemophilia Cohort Study. JAMA. Jul 10 1996; 276(2):105-110. 23. Egger M, May M, Chene G, et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. Jul 13 2002; 360(9327):119-129. 24. Anastos K, Barron Y, Cohen MH, et al. The prognostic importance of changes in CD4+ cell count and HIV-1 RNA level in women after initiating highly active antiretroviral therapy. Ann Intern Med. Feb 17 2004; 140(4):256-264. 25. O´Brien WA, Hartigan PM, Martin D, et al. Changes in plasma HIV-1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS. N Engl J Med. Feb 15 1996; 334(7):426-431. 26. Hughes MD, Johnson VA, Hirsch MS, et al. Monitoring plasma HIV-1 RNA levels in addition to CD4+ lymphocyte count improves assessment of antiretroviral therapeutic response. ACTG 241 Protocol Virology Substudy Team. Ann Intern Med. Jun 15 1997; 126(12):929-938. 27. Chene G, Sterne JA, May M, et al. Prognostic importance of initial response in HIV-1 infected patients starting potent antiretroviral therapy: analysis of prospective studies. Lancet. Aug 30 2003; 362(9385):679-686. 28. Deeks SG, Gange SJ, Kitahata MM, et al. Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America. Clin Infect Dis. Nov 15 2009; 49(10):1582-1590. 29. Quinn TC, Wawer MJ, Sewankanbo N, et al. for the Rakai Project Study Group. Viral Load and heterosexual transmission of human immunodeficiency virus type-1. NEJM 2000;342:921-929. 30. Chakraborty H., Sen, PK, Helms, RW, et.al. Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621-7. 31. Baeten JM, Kahle E, Lingappa JR, et al, Partners in Prevention HSV/HIV Transmission Study Team. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Sci Transl Med. 2011 Apr 6;3(77):77ra29. 32. Gulick RM, Mellors JW, Havlir D, et al. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretroviral therapy. N Engl J Med. 1997 Sep 11;337(11):734-9. 33. Zhang H, Dornadula G, Beumont M, et al. Human immunodeficiency virus type 1 on the semen of men receiving highly active antiretroviral therapy. N Engl J Med 1998;339:1803-1809. 34. Vernazza PL, Troiani L, Flepp MJ, et al, The Swiss HIV Cohort Study. Potent antiretroviral treatment of HIV-infection results in suppression of the seminal shedding of HIV. AIDS. 2000 Jan 28;14(2):117-21. 35. Cu-Uvin S, Caliendo AM, Reinert S, et al. Effect of highly active antiretroviral therapy on cervicovaginal HIV-1 RNA. AIDS. 2000 Mar 10;14(4):415-21. 36. Kotler DP, Shimada T, Snow G, et al. Effect of combination antiretroviral therapy upon rectal mucosal HIV RNA burden and mononuclear cell apoptosis. AIDS. 1998 Apr 16;12(6):597-604. 37. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493-505. 38. Hughes JP, Baeten JM, Lingappa JR, et al. Determinants of Per-Coital-Act HIV-1 Infectivity Among African HIV-1-Serodiscordant Couples. J Infect Dis. Feb 2012;205(3):358-365. transmission of HIV-1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621-7.


HIV: Ever screened for HIV for program(s): MSSP (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Measure not appropriate for FFS Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Screening measure does not include Medicare population. Could be appropriate for duals population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


HIV: Ever screened for HIV for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. The measure is also important to dual eligibles under age 65 years.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure closely linked to outcomes.  Applies only to ages 15-65 years.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. This measure is not yet tested. Testing in a group of community health centers that use certified EHR's systems is noted as upcoming.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No. As noted on MUC list: A similar measure has been in use at the VA for over five years and at IHS for 2 years.

Does the measure promote alignment and parsimony? Yes. This measure could be used in a variety of clinician-based settings and would promote alignment. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


HIV: Ever screened for HIV for program(s): MUEP (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


Imaging in adult ED patients with minor head injury for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3764)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure of appropriate use. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. 

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.


Imaging in adult ED patients with minor head injury for program(s): MSSP (MUC ID: X3764)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of appropriateness for MSSP. Need to consider competing measures related to ED imaging (NQF#0668).

Does the measure address a critical program objective as defined by MAP? Yes. Relates to critical program object related to appropriateness of ED imaging.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.


Imaging in pediatric ED patients aged 2 through 17 years with minor head injury for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3778)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.

Does the measure address a critical program objective as defined by MAP? . Process measure; addresses NQS priority that focusses on making quality care more affordable by developing/spreading new health care delivery models

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? No.

Is the measure currently in use? No. This measure is aligned with ACEP's Choosing Wisely recommendations, and is also aligned with the Pediatric Emergency Care Applied Research Network (PECARN), but is not found to be in use in any federal or private programs.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. A new study in JAMA demonstrated to a growing trend in ED visits for TBI, with adults older than 60 years accounting for the largest increase in rates.


In-hospital mortality following elective open repair of AAAs for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E1523)

Full Measure Specifications

NQF Number (if applicable): 1523

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: High-level outcome measure that is fully developed and NQF-endorsed.

Does the measure address a critical program objective as defined by MAP? Yes. High-value outcome measure; addresses NQS priority of making care safer by reducing harm caused in the delivery of care.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at clincian, group, practice and facility levels.

Is the measure currently in use? Yes. Vascular Study Group of New England registry

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Rationale for measure provided by HHS: Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.


In-hospital mortality following elective open repair of AAAs [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: E1523)

Full Measure Specifications

NQF Number (if applicable): 1523

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: This measure represents an important cardiac outcome for a large number of Medicare beneficiaries. This measure is currently used by private sector registries, and is undery consideration for the other PQRS-based programs. While the measure does not address care across settings, and providers, it does represent an important opportunity for quality improvement in the Medicare FFS population.

Does the measure address a critical program objective as defined by MAP? Yes.  Yes, this measure would address an important outcome for patients with a common cardiac condition. ·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response:  This measure focuses on an important cardiovascular outcome for Medicare Fee-for-Service beneficiaries[i]. Given that ruptured AAAs are the 15th leading cause of death overall in the United States, and the 10th leading cause of death in males over 55 years – it represents and important area of measurement for Medicare[ii].·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: This measure does not directly address the rate of growth of healthcare spending.·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not span multiple care settings.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: Yes. This measure is currently in use in the Vascular Study Group of New England Registry private program, but not in any federal programs. It is under consideration for use in PQRS-based programs, including Physician Compare, Physician Feedback/Quality and Resource utilization Reports, and Physician Value Based Payment Modifier Program. ·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: While this measure addresses an important cardiac quality endpoint, it does not address the high-value areas identified by MAP for this program.[i] http://www.qualityforum.org/Publications/2012/06/Surgery_Endorsement_Maintenance_2010_Technical_Report.aspx[ii] Fillinger M. (2010) Abdominal Aortic Aneurysms: Evaluation and Decision Making. In J. Cronenewett &KW. Johnston (Eds.), Rutherford´s Vascular Surgery (1928-1948) Saunders Elsevier. Philadelphia.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. This measure is currently used at least one private program (Vascular Study Group of New England registry) and is under review for multiple programs (Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, and Physician Value-Based Payment Modifier Program)

Does a review of its performance history raise any concerns? .

Does the measure promote alignment and parsimony? Yes. This measure is under consideration for multiple federal programs, applies to abroad population (all payers), and uses registries as a data source. It also aligns with the NQS priority of making care safer by reducing harm caused in the delivery of care.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Rationale for measure provided by HHS: Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient safety process eMeasure applied to all patients on warfarin. NQF has endorsed this measure but has not considered the eMeasure. Related to PQRS #380 about the time an atrial fibriallation patient's INR is in the correct range (intermediate outcome). This measure under consideration captures the broadest population of all patients taking warfarin regardless of diagnosis. In view of multiple measures for warfarin management and to promote harmonization and parsimony suggest focusing on a process (monitoring INR) and an intermediate outcome (time in therapeutic range) measure for all patients taking warfarin.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety eMeasure of appropriate medication monitoring.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? Yes.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF has not considered the eMeasure version of this measure.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): MUEP (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS measure.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF has not considered the eMeasure version of this measure.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): MSSP (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Appropriate for MSSP program. Requires coordination of care across providers. If possible, should incorporate outcome for time in therapeutic range.

Does the measure address a critical program objective as defined by MAP? Yes. High risks associated with warfarin use. Broad population measure across conditions. Requires coordination of care across providers.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Competing anticoagulation measures across conditions and programs should be reconciled..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


Intimate Partner (Domestic) Violence Screening for program(s): MSSP (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals

Does the measure address a critical program objective as defined by MAP? No. Assesses health risk without follow-up intervention. Age cut-off for measure excludes most FFS Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes.

Is the measure currently in use? Yes (Indian Health Service). Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Intimate Partner (Domestic) Violence Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: USPSTF recommends screening for intimate partner violence in all women of childbearing age (Grade B).

Does the measure address a critical program objective as defined by MAP? Yes. The measure is high value because it focuses on population health and vulnerable populations (screening for domestic violence). 

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure requires updates to new EHR standards.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? Yes. The measure is currently used by the Indian Health Services to screen high-risk NAtive Americans.

Does a review of its performance history raise any concerns? No. The IHS 2012 goal was to achieve the rate of 55.3% for the proportion of female patients aged 15-40 who receive screening for domestic violence. IHS exceeded the goal by reaching 61.5%.: (from the IHS website)

Does the measure promote alignment and parsimony? Yes. The measure is already in use in the Indian Health Program. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Intimate Partner (Domestic) Violence Screening for program(s): MUEP (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0351)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measures are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L.  Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf).  Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


Knee Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0352)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Can be matched with 3 finalized measures for knee replacement in PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures required for the VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L.  Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


MD Multidisciplinary Care Plan Developed or Updated for program(s): MSSP (MUC ID: X3791)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important specialty measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: A systematic review of muscular dystrophies has highlighted the medical complexity of caring for patients with MD. Such patients may develop cardiac, pulmonary, nutritional, and musculoskeletal complications that require the assistance of cardiologists, pulmonologists, orthopedists, physiatrists, physical therapists, occupational therapists, nutritionists, orthotists, and speech pathologists, in addition to neurologists. Additionally, myopathies with a limb-girdle, humeroperoneal, or distal pattern of weakness may be challenging to diagnose. A specific diagnosis provides patients with “closure,” assists genetic counseling, and directs monitoring for complications and optimal management.


MD Multidisciplinary Care Plan Developed or Updated for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3791)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: The 5 prior MUCs for muscular dystrophy are more specific aspects of the care plan. This process measure may add little. Conditional on testing at the clincian-level and evaluating usefulness to potential audiences.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in the measurement of speciality providers (neurologists).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. The measure is not in use in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: A systematic review of muscular dystrophies has highlighted the medical complexity of caring for patients with MD. Such patients may develop cardiac, pulmonary, nutritional, and musculoskeletal complications that require the assistance of cardiologists, pulmonologists, orthopedists, physiatrists, physical therapists, occupational therapists, nutritionists, orthotists, and speech pathologists, in addition to neurologists. Additionally, myopathies with a limb-girdle, humeroperoneal, or distal pattern of weakness may be challenging to diagnose. A specific diagnosis provides patients with “closure,” assists genetic counseling, and directs monitoring for complications and optimal management.


MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3771)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate treatment for acute migraines attacks. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? . Appropriate treament related to outcomes. Applies to 12 years of age and up.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Migraine is under diagnosed and suboptimally treated in the majority of patients. The Work Group noted although there are no guidelines available, almotriptan is approved for ages 12-17 and rizatriptan was recently approved by the FDA for ages 6-17. The Work Group also noted that although the triptans in individuals less than 12 years old may be prescribed off label, there is limited or no evidence to support this.


MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK for program(s): MSSP (MUC ID: X3771)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Migraine is under diagnosed and suboptimally treated in the majority of patients. The Work Group noted although there are no guidelines available, almotriptan is approved for ages 12-17 and rizatriptan was recently approved by the FDA for ages 6-17. The Work Group also noted that although the triptans in individuals less than 12 years old may be prescribed off label, there is limited or no evidence to support this.


Migraine Or Cervicogenic Headache Related Disability Functional Status for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3796)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: This process measure documents functional status assessment. A better measure would determine whether the disability functional status score remained the same or improved during a recent timeframe simiar to MUC X3786 for Quality of Life. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap area for the measurement of speciality care.?

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure tested for appropriate level.

Is the measure currently in use? No. Measure not in use in other programs

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the system level to indicate where improvements in the management and treatment of patients with headache should be made.


Migraine Or Cervicogenic Headache Related Disability Functional Status for program(s): MSSP (MUC ID: X3796)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the system level to indicate where improvements in the management and treatment of patients with headache should be made.


Nutritional Status or Growth Trajectories Monitored for program(s): MSSP (MUC ID: X3801)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Delayed growth, short stature, muscle wasting and increased fat mass are characteristics of DMD and impact on nutritional status and energy requirements. The early introduction of steroids has altered the natural history of the disease, but can exacerbate weight gain in a population already susceptible to obesity. Prior to commencing steroids, anticipatory guidance for weight management should be provided. Malnutrition is a feature of end stage disease requiring a multidisciplinary approach, such as texture modification and supplemental feeding. As a result of corticosteroid treatment, vitamin D and calcium should be supplemented. Patients with MD may have difficulty receiving adequate oral intake due to dysphagia and/or inability to feed themselves due to excessive arm weakness. Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life. When oral intake is inadequate, other means of maintaining intake, such as gastrostomy or jejunostomy feeding tubes, may be needed to maintain optimal nutrition. There is evidence from related conditions (amyotrophic lateral sclerosis [ALS]) that maintenance of nutrition and body weight prolongs survival.


Nutritional Status or Growth Trajectories Monitored for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3801)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life in patietns with muscular dystrophy. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in the measurement of speciality care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Delayed growth, short stature, muscle wasting and increased fat mass are characteristics of DMD and impact on nutritional status and energy requirements. The early introduction of steroids has altered the natural history of the disease, but can exacerbate weight gain in a population already susceptible to obesity. Prior to commencing steroids, anticipatory guidance for weight management should be provided. Malnutrition is a feature of end stage disease requiring a multidisciplinary approach, such as texture modification and supplemental feeding. As a result of corticosteroid treatment, vitamin D and calcium should be supplemented. Patients with MD may have difficulty receiving adequate oral intake due to dysphagia and/or inability to feed themselves due to excessive arm weakness. Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life. When oral intake is inadequate, other means of maintaining intake, such as gastrostomy or jejunostomy feeding tubes, may be needed to maintain optimal nutrition. There is evidence from related conditions (amyotrophic lateral sclerosis [ALS]) that maintenance of nutrition and body weight prolongs survival.


Optimal Asthma Care 2014 for program(s): MUEP (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Asthma Care 2014 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Composite outcome measure important to consumers. The measure has been revised to address concerns raised by NQF Steering Committee. Conditional on revised measure being submitted to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: composite, outcome; important to consumers (submitted by the Consumer-Purchaser Alliance)

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in group/practice setting. Full specifications available at http://www.health.state.mn.us/healthreform/measurement/proposedrule/msr813prp04oac.pdf.

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF reviewed this measure as a new submission in 2012. The Steering Committee did not recommend the measure at that time but thought it would ultimately be an important measure. Concerns were raised about evidence for the written management plan componen

Rationale for measure provided by HHS: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Asthma Care 2014 for program(s): MSSP (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important composite measure with patient-reported outcome measure component measure. Updated measure will be submitted to NQF for endorsement review.

Does the measure address a critical program objective as defined by MAP? Yes. Important composite measure, including Patient Reported Outcome Measure for asthma.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes (in Minnesota). Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Composite measure provides a more comprehensive view of care.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Vascular Care for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0076)

Full Measure Specifications

NQF Number (if applicable): 0076

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Revised composite outcome measure (removed the lipid component due to new guidelines) to replace the prior version finalized in PQRS. Conditional on the revised measure being submitted for NQF endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. High value measure: composite, outcomes

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? Yes. Publicly reported in Minnesota: http://www.mnhealthscores.org/medical-group-measure-detail/vascular-disease-0/#/results  

Does a review of its performance history raise any concerns? No. Recent change to specifications to remove the lipid component. No updated performance data available.  Prior version with 4 compnents: state average about 50%

Does the measure promote alignment and parsimony? Yes. This measure replaces the prior version of the measure that has been used in PQRS.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed the previous version of this measure that included the lipid outcome component. This revised measure has removed that component due to changes in the guidelines. The revised measure should be submitted to NQF.

Rationale for measure provided by HHS: According to the MN Department of Health, vascular disease is a high impact clinical condition in Minnesota. More than 20% of all deaths in Minnesota are due to heart disease and more than 6% are due to stroke, making them the second and third leading causes of death, respectively, in the state behind cancer. Inpatient hospitalization charges alone in Minnesota were more than $1.85 billion for heart disease patients and $362 million for stroke patients in 2008. Risk factors reported by Minnesotans include 34% high blood cholesterol, 22% high blood pressure, 16.7% cigarette smoke, 6.7% diabetes, 62% overweight, and 16% physical inactivity. 1a.4 Citations for Evidence of High Impact: Minnesota Department of Health 2010 Fact Sheets on Heart Disease and Stroke in Minnesota; http://www.health.state.mn.us/divs/hpcd/chp/cvh/Data.htm


Optimal Vascular Care for program(s): MSSP (MUC ID: E0076)

Full Measure Specifications

NQF Number (if applicable): 0076

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Composite outcome measure for highly prevalent condition important to Medicare patients. Conditonal on successful maintenace review of revised measure by NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value composite outcome measure for coronary artery disease - a highly prevalent condition in the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. In use in Minnesolta.

Is the measure currently in use? Yes. Minnesota Quality Scores.Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate: Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?This composite outcome measure would address the same aspects of care as multiple, individual outcome and process measures..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed a previous version with 4 components (lipd component has since been removed to align with new guidelines).

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: According to the MN Department of Health, vascular disease is a high impact clinical condition in Minnesota. More than 20% of all deaths in Minnesota are due to heart disease and more than 6% are due to stroke, making them the second and third leading causes of death, respectively, in the state behind cancer. Inpatient hospitalization charges alone in Minnesota were more than $1.85 billion for heart disease patients and $362 million for stroke patients in 2008. Risk factors reported by Minnesotans include 34% high blood cholesterol, 22% high blood pressure, 16.7% cigarette smoke, 6.7% diabetes, 62% overweight, and 16% physical inactivity. 1a.4 Citations for Evidence of High Impact: Minnesota Department of Health 2010 Fact Sheets on Heart Disease and Stroke in Minnesota; http://www.health.state.mn.us/divs/hpcd/chp/cvh/Data.htm


Overuse of Barbiturate Containing Medications for Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3765)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Appropriate use measure, but title is misleading since the measure assess the percentage of patients NOT prescribed barbiturates rather than first line drugs. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure addressing inappropriate use of barbiturates rather than first line drugs.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. However, barbiturates or butalbital containing agents are prescribed frequently. The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. One study noted that barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to a tertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%).


Overuse of Barbiturate Containing Medications for Primary Headache Disorders for program(s): MSSP (MUC ID: X3765)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. However, barbiturates or butalbital containing agents are prescribed frequently. The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. One study noted that barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to a tertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%).


Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3785)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Appropriate use measure.  Conditional on testing at the clincian level and submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriate use measure for imaging.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. MUC list does not note level of testing?

Is the measure currently in use? No. Not used in other programs

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.


Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination for program(s): MSSP (MUC ID: X3785)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Conditional on measure testing and submission to NQF for endorsement. Multiple headache measures may be appropriate for a MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Potential inappropriate imaging for headache.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.


Overuse Of Opioid Containing Medications For Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3770)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: Duplicative of measure underconsideration X3774 for patients taking opioid regardless of diagnosis.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure measure for assessment of opiod overuse.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. Duplicative and less specific than measure under consideration X3774 that specifies use of a screening tool and applies to all opioid users, not just patients with headaches.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. The use of barbiturates or opioids increases the risk of chronic daily headache and drug induced hyperalgesia. In one study, any use of barbiturates and opiates was associated with increased risk of transformed migraine after adjusting for covariates, while triptans were not. In a sample of 5,796 people with headache, 4,076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users.


Overuse Of Opioid Containing Medications For Primary Headache Disorders for program(s): MSSP (MUC ID: X3770)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. The use of barbiturates or opioids increases the risk of chronic daily headache and drug induced hyperalgesia. In one study, any use of barbiturates and opiates was associated with increased risk of transformed migraine after adjusting for covariates, while triptans were not. In a sample of 5,796 people with headache, 4,076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users.


Patient Counseled About Health Care Decision-Making for program(s): MSSP (MUC ID: X3789)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: An important aspect of ongoing management includes proactively preparing patients with MD and their families for the long-term consequences of muscular dystrophies and engaging in discussions regarding end-of-life care. This helps patients come to terms with their condition and prepare for the expected complications of their form of MD and avoids the need for hasty decisions made in the throes of a medical crisis. Palliative care is useful to alleviate the suffering of these patients.


Patient Counseled About Health Care Decision-Making for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3789)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Care coordination addressing advanced directives and end-of life planning.  Important for dual eligibles. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Fills a gap in a new condition area.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: An important aspect of ongoing management includes proactively preparing patients with MD and their families for the long-term consequences of muscular dystrophies and engaging in discussions regarding end-of-life care. This helps patients come to terms with their condition and prepare for the expected complications of their form of MD and avoids the need for hasty decisions made in the throes of a medical crisis. Palliative care is useful to alleviate the suffering of these patients.


Patient Queried about Pain and Pain Interference with Function for program(s): MSSP (MUC ID: X3800)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Between 68-82% of patients with muscular dystrophies live in pain. Pain is a common feature of some MDs, notably myotonic dystrophy and FSHD, but also many of the limb girdle muscular dystrophies (LGMDs). Pain interferes with physical and psychological functioning in these patients. Lower extremity pain intuitively affects ambulation. Pain and fatigue are independent predictors of lower physical functioning and greater depression. Thus identification and treatment of pain is important to improve the care of patients with MD.


Patient Queried about Pain and Pain Interference with Function for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3800)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Process measure addresses systematic assessment for pain. Conditional on successful testing at the clinican level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure satisfies a gap area in its' assessment of muscular dystrophy and promotes partcicipation among eligible professionals. 

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The level of analysis is not indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Between 68-82% of patients with muscular dystrophies live in pain. Pain is a common feature of some MDs, notably myotonic dystrophy and FSHD, but also many of the limb girdle muscular dystrophies (LGMDs). Pain interferes with physical and psychological functioning in these patients. Lower extremity pain intuitively affects ambulation. Pain and fatigue are independent predictors of lower physical functioning and greater depression. Thus identification and treatment of pain is important to improve the care of patients with MD.


Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy for program(s): MSSP (MUC ID: X3787)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: DMD is a recessive X- linked genetic disorder characterized by progressive muscle weakness and reduced muscle tone. Affecting only boys, it limits life expectancy to approximately 20 years. Care for patients with DMD is poorly standardized. This leads to inequality in access to treatment. Although there is no cure, a Cochrane Review and AAN practice parameter concluded that prednisone may provide short term effective treatment that prolongs the ability to walk, reduces the complications such as scoliosis, respiratory insufficiency and cardiac impairment. Despite the well documented beneficial effects of corticosteroids in DMD, a population based study of corticosteroid use between 1991 and 2005 reported that only 50.9% of individuals had ever been on corticosteroids. The annual mean percent corticosteroid use varied widely from 8.4% to 80.2% across clinics. Another survey showed that nearly 10% of neuromuscular disease clinics do not offer such therapy. Glucocorticoids are currently the only medication available that slows the decline in muscle strength and function in DMD, which in turn reduces the risk of scoliosis and stabilizes pulmonary function. Approximately 16% of Muscular Dystrophy Association clinic directors report not using corticosteroids.


Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3787)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Muscular dystrophy is a group of nine inherited diseases of progressive muiscle weakness affecting more than 50,000 Americans. This process measure in new condition area measures use of evidence-based therapy that can slow the progression of the disease. Conditional on satisfactory testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in speciality care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. There are no notes on level of analysis.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by allowing the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: DMD is a recessive X- linked genetic disorder characterized by progressive muscle weakness and reduced muscle tone. Affecting only boys, it limits life expectancy to approximately 20 years. Care for patients with DMD is poorly standardized. This leads to inequality in access to treatment. Although there is no cure, a Cochrane Review and AAN practice parameter concluded that prednisone may provide short term effective treatment that prolongs the ability to walk, reduces the complications such as scoliosis, respiratory insufficiency and cardiac impairment. Despite the well documented beneficial effects of corticosteroids in DMD, a population based study of corticosteroid use between 1991 and 2005 reported that only 50.9% of individuals had ever been on corticosteroids. The annual mean percent corticosteroid use varied widely from 8.4% to 80.2% across clinics. Another survey showed that nearly 10% of neuromuscular disease clinics do not offer such therapy. Glucocorticoids are currently the only medication available that slows the decline in muscle strength and function in DMD, which in turn reduces the risk of scoliosis and stabilizes pulmonary function. Approximately 16% of Muscular Dystrophy Association clinic directors report not using corticosteroids.


PC-02 Cesarean Section (Provider Level) for program(s): MSSP (MUC ID: X3788)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important measure. Not appropriate for Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Important appropriateness measure. Not appropriate for Medicare FFS population

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Needs clinician level testing.

Is the measure currently in use? Yes (at provider level only). Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Fully aligned provider and clinician level measure would contribute to efficient use of measurement resources.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This AMA – PCPI measure is harmonized with the Joint Commission’s measure (PC-02 Cesarean Section) in language and intent. The Joint Commission measure is a facility-level measures whereas this measure includes attribution at the individual provider level measure Cesarean deliveries are performed for many reasons. Some, such as those for breech presentation, are supported by strong clinical consensus. However, many cesareans, especially those done in the course of labor, are the result of labor management practices that vary widely and suggest clinician discretion (CMQCC) There is growing evidence to support the claim that provider-dependent indications (i.e., those that rely on provider judgment) combined with provider discretion contribute significantly to the overall increase in both primary and repeat cesareans. The fact that cesarean delivery rates and practices vary widely among states, regions, hospitals, and providers for both primary and repeat cesareans demonstrates that hospitals and clinicians can differ in their responses to the same conditions. This fact suggests the need for more precise clinical practice guidelines and/or greater accountability and incentives for following them. (California Maternal Quality Care Collaborative) California Maternal Quality Care Collaborative clinician interviews (funded by California HealthCare Foundation) reveal that many nurses talked about the timing of cesareans done during labor, citing the competing demands on physicians for clinic appointments and their desire for balance between work and the rest of life. Institutional pressures and the pace of high-volume facilities was another factor mentioned, along with physicians’ impatience with labor progress—a response that can be exacerbated in clinicians and mothers alike by the use of inductions, which can set up an expectation for a quick birth experience


PC-02 Cesarean Section (Provider Level) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3788)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: Duplicative of measure under consideration X3768 that is already in use in private programs.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, outcome measure that fills a gap area? and provides more measures for obstetricians.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. A similar measure underconsideration X3768 Primary C-section rate 2014 from MNCM is already in use in provate programs in MN.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. The facility-level measure for hospitals is endorsed by NQF.

Rationale for measure provided by HHS: This AMA – PCPI measure is harmonized with the Joint Commission’s measure (PC-02 Cesarean Section) in language and intent. The Joint Commission measure is a facility-level measures whereas this measure includes attribution at the individual provider level measure Cesarean deliveries are performed for many reasons. Some, such as those for breech presentation, are supported by strong clinical consensus. However, many cesareans, especially those done in the course of labor, are the result of labor management practices that vary widely and suggest clinician discretion (CMQCC) There is growing evidence to support the claim that provider-dependent indications (i.e., those that rely on provider judgment) combined with provider discretion contribute significantly to the overall increase in both primary and repeat cesareans. The fact that cesarean delivery rates and practices vary widely among states, regions, hospitals, and providers for both primary and repeat cesareans demonstrates that hospitals and clinicians can differ in their responses to the same conditions. This fact suggests the need for more precise clinical practice guidelines and/or greater accountability and incentives for following them. (California Maternal Quality Care Collaborative) California Maternal Quality Care Collaborative clinician interviews (funded by California HealthCare Foundation) reveal that many nurses talked about the timing of cesareans done during labor, citing the competing demands on physicians for clinic appointments and their desire for balance between work and the rest of life. Institutional pressures and the pace of high-volume facilities was another factor mentioned, along with physicians’ impatience with labor progress—a response that can be exacerbated in clinicians and mothers alike by the use of inductions, which can set up an expectation for a quick birth experience


Pediatric Kidney Disease: Discussion of Care Planning for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3733)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Pediatric care coordination measure. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority of focusing on patient- and family-centered care;

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Also tested at individual practice; group practice level

Is the measure currently in use? No. QCDR

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Institute family-centered care planning for children and adolescents with CKD and ESRD. The plan should establish treatment goals based on a child’s medical condition and prognosis. (RPA, 2010) Care planning should be an ongoing process in which treatment goals are determined and revised based on observed benefits and burdens of dialysis and the values of the pediatric patient and the family. The renal care team should designate a person to be primarily responsible for ensuring that care planning is offered to each patient. Patients with decision-making capacity should be strongly encouraged to talk to their parents to ensure that they know the patient’s wishes and agrees to make decisions according to these wishes. Ongoing discussions that include reestablishing goals of care based on the child’s response to medical treatment and optimal quality of life is the mechanism by which care planning occurs. Discussions should include pros and cons of dialysis as well as potential morbidity associated with dialysis. Kidney transplantation should also be discussed if appropriate. (RPA, 2010)


Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3739)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is a process measure of patients receiving a survey before and after the procedure. Suggest developing as a patient-reported outcome measure that compares the survey results before and after surgery.

Does the measure address a critical program objective as defined by MAP? Yes. This process measure assesses use of a patient reported outcome survey but the results are not used as a PRO outcome measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. No level of analysis indicated, however measure can be applied at the clinical level to assess the number of treatements rendered and surveys provided by a clinician.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: Surrogate measures for success of saphenous ablation have numerous flaws. The ultimate measure of success of saphenous ablation in patients with varicose veins is improved quality of life. This quality measure motivates physicians to assess quality of life after an ablation as compared with before an ablation to understand the improvement in quality of life that they offer their patients. Eventually, some threshold for improvement based on disease state may serve as a benchmark for quality care. The Intersocietal Accreditation Commission-Vein Center Division strongly recommends the use of the disease specific patient reported outcome (PRO) instrument before and after ablation and to use the data collected for an analysis of the quality of care being delivered by the center (1).These guidelines have been created by the IAC and are being implemented by several groups including SVS. 1. “Vein Center Accreditation A Process to Demonstrate a Commitment to Quality Vein Care.” March 11, 2014. http://www.veindirectory.org/magazine/article/vein_center_accreditation_a_process_to_demonstrate_a_commitment_to_quality_vein_care The American Venous Forum recommends the use of PRO before and after vein treatment for all patients (2). 2. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.” May 2011. http://www.bendvein.com/downloads/Journal-Vascular-Surgery.pdf


Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment for program(s): MSSP (MUC ID: X3739)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. Preference for PROM with patient results.

Does the measure address a critical program objective as defined by MAP? No. Patient-reported process measure. Does not address MSSP program objectives.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Surrogate measures for success of saphenous ablation have numerous flaws. The ultimate measure of success of saphenous ablation in patients with varicose veins is improved quality of life. This quality measure motivates physicians to assess quality of life after an ablation as compared with before an ablation to understand the improvement in quality of life that they offer their patients. Eventually, some threshold for improvement based on disease state may serve as a benchmark for quality care. The Intersocietal Accreditation Commission-Vein Center Division strongly recommends the use of the disease specific patient reported outcome (PRO) instrument before and after ablation and to use the data collected for an analysis of the quality of care being delivered by the center (1).These guidelines have been created by the IAC and are being implemented by several groups including SVS. 1. “Vein Center Accreditation A Process to Demonstrate a Commitment to Quality Vein Care.” March 11, 2014. http://www.veindirectory.org/magazine/article/vein_center_accreditation_a_process_to_demonstrate_a_commitment_to_quality_vein_care The American Venous Forum recommends the use of PRO before and after vein treatment for all patients (2). 2. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.” May 2011. http://www.bendvein.com/downloads/Journal-Vascular-Surgery.pdf


Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3755)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure of follow-up after procedure performed by interventional radiologists.

Does the measure address a critical program objective as defined by MAP? Yes. A measure for follow-up of prior procedure for interventional radiologists.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. No level of analysis indicated, however measure can be applied at the clinical level to assess the number of treatements rendered and surveys provided by a clinician.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignement due to lack of testing and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: Retrievable filter complications have been increasingly noted in the FDA MAUDE database and in the literature. Retrievable filters were designed differently than permanent filters and the incidence of device related complications with long term insertions are higher than in comparison to permanent filters. The FDA has recommended that physicians that place these filters, carefully monitor these patients and remove these filters at the earliest possible time. The proposed quality measure will encourage physicians who place filters to follow-up with their patients at 3 months and document that a decision has been made to either a) remove the filter, b) document that re-assessment has established the appropriateness of continued filter use or c) documentation of at least two attempts to reach the patient, proxy or primary care provider to arrange a clinical re-assessment for the appropriateness of filter removal. Dedicated follow-up for IVC filters has led to an increase in retrieval rate (1). FDA recommends that all physicians placing IVC Filters and those responsible for ongoing care of these patients, remove the filter as soon as protection from PE is no longer needed. The FDA encourages follow-up on patients to consider risks and benefits of filter removal (2,3,4). Data on IVC Filters will be collected through the PRESERVE trial which is sponsored by teh IVC Filter Study Group Foundation. This trial will look at commercially available IVC Filters (retrievable) from participating manufacturers. The study objective is to evaluate the safety and effectiveness of participating IVC Filters in subjects with clinical need for mechanical prophylaxis of PE. 1. Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 2. “Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Uses.” August, 9, 2010. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm221707.htm 3. “Removing Retrievable Inferior Vena Cava Filters: Initial Communication.” August 9, 2010. http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm221676.htm Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 4. “Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication.” Amy 6, 2014. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm


Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal for program(s): MSSP (MUC ID: X3755)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important appropriateness measure. Does not address MSSP program objectives.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Retrievable filter complications have been increasingly noted in the FDA MAUDE database and in the literature. Retrievable filters were designed differently than permanent filters and the incidence of device related complications with long term insertions are higher than in comparison to permanent filters. The FDA has recommended that physicians that place these filters, carefully monitor these patients and remove these filters at the earliest possible time. The proposed quality measure will encourage physicians who place filters to follow-up with their patients at 3 months and document that a decision has been made to either a) remove the filter, b) document that re-assessment has established the appropriateness of continued filter use or c) documentation of at least two attempts to reach the patient, proxy or primary care provider to arrange a clinical re-assessment for the appropriateness of filter removal. Dedicated follow-up for IVC filters has led to an increase in retrieval rate (1). FDA recommends that all physicians placing IVC Filters and those responsible for ongoing care of these patients, remove the filter as soon as protection from PE is no longer needed. The FDA encourages follow-up on patients to consider risks and benefits of filter removal (2,3,4). Data on IVC Filters will be collected through the PRESERVE trial which is sponsored by teh IVC Filter Study Group Foundation. This trial will look at commercially available IVC Filters (retrievable) from participating manufacturers. The study objective is to evaluate the safety and effectiveness of participating IVC Filters in subjects with clinical need for mechanical prophylaxis of PE. 1. Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 2. “Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Uses.” August, 9, 2010. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm221707.htm 3. “Removing Retrievable Inferior Vena Cava Filters: Initial Communication.” August 9, 2010. http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm221676.htm Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 4. “Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication.” Amy 6, 2014. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm


Performing an intraoperative rectal examination at the time of prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3740)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety process measure may have less value than the adverse outcome measure (X3744). Consider pairing the process and outcome measure. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Outcome measure; Clinically relevant to urologists; addresses NQS priority of focusing on making care safer by reducing harm caused in the delivery of care.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at individual and group practice level

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Rectal injuries occur with surgery for pelvic organ prolapse involving the posterior and apical vaginal compartments. Correcting such injuries at the time they occur is preferable over delayed recognition due to an increase in morbidity and the need for additional surgery. Therefore, performing and documenting a rectal examination during the surgery would help identify such rectal injury in a timely manner and would potentially increase the safety in performing such surgeries.


Performing an intraoperative rectal examination at the time of prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3740)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: This process measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care. 

Does the measure address a critical program objective as defined by MAP? Yes. This process measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response:  Prolapse repair is a common procedure with 100,000 to 200,000 surgeries performed per year; however it does not address the overall health of the Medicare population. In addition to impacting a large number of individuals, the cost of treatment and rate of complications are high[i].[i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not address care delivered across providers in multiple care settings.·        Promote alignment across other quality measurement reporting programs (e.g., end of life palliative care) ;·        Response: N/A·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: The measure does not address any of the high-value measure domains identified by the MAP for the Medicare Shared Savings Program.[i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. This measure is not currently in use in any federal or private programs. However, it is being considered for multiple PQRS-based programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, and the Physician Value Based Payment Modifier Program.

Does the measure promote alignment and parsimony? No. This measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Rectal injuries occur with surgery for pelvic organ prolapse involving the posterior and apical vaginal compartments. Correcting such injuries at the time they occur is preferable over delayed recognition due to an increase in morbidity and the need for additional surgery. Therefore, performing and documenting a rectal examination during the surgery would help identify such rectal injury in a timely manner and would potentially increase the safety in performing such surgeries.


Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3752)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: NQF-endorsed patient safety process measure to identify and correct potential complications during surgery. Recommend pairing with the outcome measure X3743 when developed.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure for detection of a potential adverse outcomes.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure tested at individual and group practice levels.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure #2063 was endorsed in November, 2014.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Lower urinary tract (bladder and/or ureter(s)) injury is a common complication of prolapse repair surgery, occurring in up to 5% of patients. Delay in detection of lower urinary tract injury has an estimated cost of $54, 000 per injury (Visco et al), with significant morbidity for patients who experience them. Universal cystoscopy may detect up to 97% of all injuries at the time of surgery (Ibeanu et al, 2009), resulting in the prevention of significant morbidity and providing significant cost savings (over $108 million per year) In a recent study we found that 84.5% (539/638) performed cystoscopy 97% of high volume surgeons performed a cystoscopy at the time of hysterectomy for pelvic organ prolapse while low volume surgeons performed this procedure only 75 % of the time (p<.001).


Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3752)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary:

Does the measure address a critical program objective as defined by MAP? Yes.  Lower urinary tract injury is a common complication of this type of surgery.·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i],[ii].  Lower urinary tract injury is a common complication of this type of surgery. ·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: The measure does not address care delivered across care settings or providers. ·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: N/A·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This measure does not address any of the high-value measurement domains identified for the Medicare Shared Savings program.[i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.[ii] Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Lower urinary tract (bladder and/or ureter(s)) injury is a common complication of prolapse repair surgery, occurring in up to 5% of patients. Delay in detection of lower urinary tract injury has an estimated cost of $54, 000 per injury (Visco et al), with significant morbidity for patients who experience them. Universal cystoscopy may detect up to 97% of all injuries at the time of surgery (Ibeanu et al, 2009), resulting in the prevention of significant morbidity and providing significant cost savings (over $108 million per year) In a recent study we found that 84.5% (539/638) performed cystoscopy 97% of high volume surgeons performed a cystoscopy at the time of hysterectomy for pelvic organ prolapse while low volume surgeons performed this procedure only 75 % of the time (p<.001).


Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0465)

Full Measure Specifications

NQF Number (if applicable): 0465

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: NQF-endorsed measure. Evidence-based process measure that promotes secondary prevention of vasular disease beyond the timeframe of surgery. Complements two outcome measures for this procedure.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure closely related to long-term outcomes; care coordination for secondary prevention of vascular disease.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Society of Vascular Surgery provides feeedback to participants.  The reigstry target for this measure is 90%.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Clinician-level measure.

Rationale for measure provided by HHS: The Vascular Study Group of Northern New England (VSGNNE) has published validated registry data from 48 surgeons in 9 hospitals concerning more than 3000 patients undergoing CEA (Cronenwett, 2007). This demonstrated initially that only 82% of patients were taking ASA or clopidogrel preoperatively before CEA in 2004. Through quality improvement efforts, this percentage has increased to 91% during the first 6 months of 2007. Further, a recent study from Austria found that 37% of 206 patients undergoing CEA were not on preoperative antiplatelet therapy, and concluded that this practice does not meet current guidelines and provides substantial opportunity for improvement (Assadian, 2006).


Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: E0465)

Full Measure Specifications

NQF Number (if applicable): 0465

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: This fully developed and tested endorsed measure assessesaddresses the safety of patients by evaluatingappropriate use of medications before and after procedure. It also requires a level of coordination and collaboration within ACO. 

Does the measure address a critical program objective as defined by MAP? Yes. This measure does not address any of the critical program objectives or identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.§ Yes, this measure addresses the safety of patients undergoing Carotid Endarterectomy, which is a high risk procedure for the Medicare population. ·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: This measure addresses the safety ofpatients undergoing Carotid Endarterectomy, which is a high risk procedure for the Medicare population. ·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: This measure does not directly address the rate of growth of health care spending.·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not measure care across settings of care or providers. ·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure does not promote alignment across quality measurement programs since it is currently not in use. The measure is under consideration in PQRS-based programs.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response:This process measure does not address the high-value measurement domains identified by the MAP. 

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No. This measure is not currently in use in any federal or private programs. It is under consideration for use in PQRS-based programs, including: Physician Compare, Physician Feedback/Quality and Resource utilization Reports, and Physician Value Based Payment Modifier Program.

Does the measure promote alignment and parsimony? Yes.   This measure has the potential to promote alignment since the measure is currently under review for multiple programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Rationale for measure provided by HHS: The Vascular Study Group of Northern New England (VSGNNE) has published validated registry data from 48 surgeons in 9 hospitals concerning more than 3000 patients undergoing CEA (Cronenwett, 2007). This demonstrated initially that only 82% of patients were taking ASA or clopidogrel preoperatively before CEA in 2004. Through quality improvement efforts, this percentage has increased to 91% during the first 6 months of 2007. Further, a recent study from Austria found that 37% of 206 patients undergoing CEA were not on preoperative antiplatelet therapy, and concluded that this practice does not meet current guidelines and provides substantial opportunity for improvement (Assadian, 2006).


Perioperative Temperature Management for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3809)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Intermediate outcome measure revised from a prior process measure. Additional measure for anesthesia. Recommend clarification of the specifications as discussed with the NQF Surgery Standing Committee in May 2014 as the measure is further developed and tested.

Does the measure address a critical program objective as defined by MAP? Yes. This is an outcome measure that satisfies a gap area in its' assessment of body temperature in relation to anesthesia administration.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and peformance inforamtion.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure was reviewed by NQF Surgery Committee in May 2014. Many question about the specifications promptin gthe measure steward to withdraw the measure from consideration.

Rationale for measure provided by HHS: A drop in core temperature during surgery, known as perioperative hypothermia, can result in numerous adverse effects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence of surgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical effects due to perioperative hypothermia, is affected by maintenance of normothermia during surgery.


Perioperative Temperature Management [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3809)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: This measure has been retired by the measure steward, CMS.

Does the measure address a critical program objective as defined by MAP? No.         Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: N/A·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not address care across settings or providers·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: ·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This measure does not address the high value measurement domains identified by MAP for the Medicare Shared Savings Program.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? No. This measure has been retired by CMS, the measure steward. Continued use of this measure would not support an efficient use of measurement resources.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: A drop in core temperature during surgery, known as perioperative hypothermia, can result in numerous adverse effects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence of surgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical effects due to perioperative hypothermia, is affected by maintenance of normothermia during surgery.


Photodocumentation of cecal intubation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3761)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure captures the completenss of the colonoscopy procedures used for screening and surveillence for colorectal cancer. Suggest a composite measure to combine multiple measures of colonoscopy performance.

Does the measure address a critical program objective as defined by MAP? Yes. This measure captures the completeness of the colonoscopy procedure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy. Effective colonoscopists should be able to intubate the cecum in > 90% of cases, and in > 95% of cases when the indication is screening in a healthy adult. Studies have shown that physicians do not routinely document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon – from the rectum to the cecum. Knowing the depth of insertion can inform physicians of whether a radiographic procedure or repeat colonoscopy is necessary. However, the lack of comprehensive documentation can lead to unnecessary or repeat tests.


Photodocumentation of cecal intubation for program(s): MSSP (MUC ID: X3761)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure regarding colonoscopy adequacy. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Measure reflects adequacy of colonoscopy.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy. Effective colonoscopists should be able to intubate the cecum in > 90% of cases, and in > 95% of cases when the indication is screening in a healthy adult. Studies have shown that physicians do not routinely document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon – from the rectum to the cecum. Knowing the depth of insertion can inform physicians of whether a radiographic procedure or repeat colonoscopy is necessary. However, the lack of comprehensive documentation can lead to unnecessary or repeat tests.


Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3794)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: This plan of care measure does not add much to measure X3771 and X3772 that discuss acute and preventive treatment.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in measurement for speciality providers.?

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure fully tested. No notes on level or setting tested.

Is the measure currently in use? No. Measure not noted to be in use in other programs.

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by allowing the participating of specality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Optimizing headache management requires a systematic assessment of symptoms, including the development of an individualized plan of care. Clinicians are advised to base their treatment choice on degree of disability along with attack frequency and duration, non-headache symptoms, patient preference, and prior history of treatment response, using a stratified approach to care. This information should be included in the patient’s plan of care. HRQoL and disability are positively impacted by treatment interventions and a continuity of care.


Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed for program(s): MSSP (MUC ID: X3794)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure in gap area. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Optimizing headache management requires a systematic assessment of symptoms, including the development of an individualized plan of care. Clinicians are advised to base their treatment choice on degree of disability along with attack frequency and duration, non-headache symptoms, patient preference, and prior history of treatment response, using a stratified approach to care. This information should be included in the patient’s plan of care. HRQoL and disability are positively impacted by treatment interventions and a continuity of care.


Plan Of Care Or Referral For Possible Medication Overuse Headache for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3784)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: This process measure follows up on the screening for medication overuse in MUC X3783. Consider pairing the measures. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority - promoting the most effective prevention and treatment practices; high value measure - addresses patient safety.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired, or a two-part measure, that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III medication overuse headache criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose.


Plan Of Care Or Referral For Possible Medication Overuse Headache for program(s): MSSP (MUC ID: X3784)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired, or a two-part measure, that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III medication overuse headache criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose.


Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3810)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for realiability and valdiity and meaningful differences among anesthesia providers will be important.

Does the measure address a critical program objective as defined by MAP? Yes. An additional measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is currently being used in PQRS (Qualified Clinical Data Registry Option) then it should easily align with the established objectives for inclusion in the other PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Peri-procedure transitions of care place patients at risk for incomplete sharing of important information between practitioners. Effective communication between providers at the time of admission to PACU promotes safe care and enhances coordination of care.


Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3810)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU). The measure does encourage coordination within an acute care facility among providers. The measure does have the potential to improve surgical and anesthesia care for the Medicare population. 

Does the measure address a critical program objective as defined by MAP? Yes.         Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: While this measure does not address the overall health of the Medicare FFS population, it does focus on a subset of beneficiaries who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU).·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: This measure does not directly address the growth rate of healthcare spending.·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: While this measure does encourage coordination within an acute care facility among providers, it doesn’t address care across settings. ·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure is being considered for PQRS-based programs.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This measure does not address the high-value measure domains identified by the MAP for MSSP.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs. 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Peri-procedure transitions of care place patients at risk for incomplete sharing of important information between practitioners. Effective communication between providers at the time of admission to PACU promotes safe care and enhances coordination of care.


Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3807)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for reliability and valdity and meaningful differences among anesthesia providers will be important.

Does the measure address a critical program objective as defined by MAP? Yes. Another measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is currently being used in PQRS (Qualified Clinical Data Registry Option) then it should easily align with the established objectives for inclusion in the other PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: A uniform transfer of care protocol or handoff tool/checklist that is utilized for all patients directly admitted to the ICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effective communications between the medical practitioner who provided anesthesia during the procedure and the care practitioner in the ICU who is responsible for post-procedural care. This should minimize errors and oversights in medical care of ICU patients after procedures. Hand-offs of care are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia providers routinely transfer critically ill patients from the OR to the ICU, and are responsible for transmitting knowledge about patient history, a summary of intraoperative events, and future plans for hemodynamic and pain management to the ICU team. Evidence demonstrates that this process can be facilitated by use of a checklist that motivates completion of all key components of the transfer. This is an emerging best practice in anesthesia care.


Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3807)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for in the OR and are transferred to the ICU andencourages coordination within an acute care facility among providers. The measure also has the potential to improve surgical and anesthesia care for the Medicare population. 

Does the measure address a critical program objective as defined by MAP? Yes.  This measure has the potential to improve coordination and care improvement from the OR to the ICU. ·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: This measure focuses on patients who undergoprocedure under anesthesia and are admitted to an Intensive Care Unit (ICU). ·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response:  This measure does not directly address the growth rate of healthcare spending.·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: While this measure encourages coordination across multiple points of care within the hospital, it does not span across care settings or providers.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care);·        Response: This measure is being considered for other PQRS-based programs.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response:  This measure does not address the MAP identified high-value measurement areas or gaps for this program.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? Yes. The measure has the potential to promote alignment across programs by being under consideration for multiple programs. 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: A uniform transfer of care protocol or handoff tool/checklist that is utilized for all patients directly admitted to the ICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effective communications between the medical practitioner who provided anesthesia during the procedure and the care practitioner in the ICU who is responsible for post-procedural care. This should minimize errors and oversights in medical care of ICU patients after procedures. Hand-offs of care are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia providers routinely transfer critically ill patients from the OR to the ICU, and are responsible for transmitting knowledge about patient history, a summary of intraoperative events, and future plans for hemodynamic and pain management to the ICU team. Evidence demonstrates that this process can be facilitated by use of a checklist that motivates completion of all key components of the transfer. This is an emerging best practice in anesthesia care.


Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3746)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure that contrbutes to approrpiate use of surgery.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: When a woman with pelvic organ prolapse experiences urinary leakage only when the prolapse is reduced, her condition is called an occult stress urinary incontinence. The underlying cause may be urethral compression or urethral kinking. The percentage of patients in whom evidence of occult stress urinary incontinence is discovered prior to prolapse surgery varies from 23 to 69%. According to the guidelines of the German society of obstetrics and gynecology, a stress test with and without reduction of the prolapse should be conducted prior to prolapse surgery . Guidelines of the International Continence Society go even further, stating urodynamic investigations with and without stress test should be included in the diagnostic workup of patients prior to prolapse surgery. While several studies have shown improved urinary incontinence rates following prolapse surgery that included an anti-incontinence component, the potential risks of adding another procedure must be considered as well. A systematic review and meta-analysis of randomized trials concluded that in the group of women with occult stress urinary incontinence there is a lower incidence of objective stress urinary incontinence after combined (prolapse+sling) surgery 22% versus 52% with no difference in bladder storage symptoms, urgency incontinence, and long-term obstructive voiding symptoms. However, to benefit from this data and to support good decision-making, the surgeon must determine whether there is or isn't occult stress incontinence preoperatively. In a recent study we found that 78.6% of patients had a pre-operative stress test and that 93.5% of high volume surgeons evaluated their patients for occult prior to surgery for pelvic organ prolapse while 63% of low volume surgeons and 72% of intermediate volume surgeons did.


Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3746)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: This measure addresses a gap in speciality measurement. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. The measure fills a gap in speciality care measurement. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Measure being specified and tested?

Is the measure currently in use? No. Measure not yet used in any programs.Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? ?This measure promotes alignment by involving specialities in program reporting..

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: When a woman with pelvic organ prolapse experiences urinary leakage only when the prolapse is reduced, her condition is called an occult stress urinary incontinence. The underlying cause may be urethral compression or urethral kinking. The percentage of patients in whom evidence of occult stress urinary incontinence is discovered prior to prolapse surgery varies from 23 to 69%. According to the guidelines of the German society of obstetrics and gynecology, a stress test with and without reduction of the prolapse should be conducted prior to prolapse surgery . Guidelines of the International Continence Society go even further, stating urodynamic investigations with and without stress test should be included in the diagnostic workup of patients prior to prolapse surgery. While several studies have shown improved urinary incontinence rates following prolapse surgery that included an anti-incontinence component, the potential risks of adding another procedure must be considered as well. A systematic review and meta-analysis of randomized trials concluded that in the group of women with occult stress urinary incontinence there is a lower incidence of objective stress urinary incontinence after combined (prolapse+sling) surgery 22% versus 52% with no difference in bladder storage symptoms, urgency incontinence, and long-term obstructive voiding symptoms. However, to benefit from this data and to support good decision-making, the surgeon must determine whether there is or isn't occult stress incontinence preoperatively. In a recent study we found that 78.6% of patients had a pre-operative stress test and that 93.5% of high volume surgeons evaluated their patients for occult prior to surgery for pelvic organ prolapse while 63% of low volume surgeons and 72% of intermediate volume surgeons did.


Preoperative assessment of sexual function prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3742)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in speciality measurement.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No. Measure not used in programs

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by involving speciality providers in program reporting

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Since surgeries to correct urinary incontinence and pelvic organ prolapse in women aim to improve quality of life, it is also important to assess sexual function, which affects quality of life and often improves after these types of surgeries. By assessing preoperative sexual function, we will be able to assess if sexual function is regained, improves, or worsens after these types of surgeries. Because urinary incontinence and pelvic organ prolapse tend to occur in middle age, these are modifiable conditions that can be successfully treated and contribute to healthy aging and improved quality of life.


Preoperative assessment of sexual function prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3742)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Since surgeries to correct urinary incontinence and pelvic organ prolapse in women aim to improve quality of life, it is also important to assess sexual function, which affects quality of life and often improves after these types of surgeries. By assessing preoperative sexual function, we will be able to assess if sexual function is regained, improves, or worsens after these types of surgeries. Because urinary incontinence and pelvic organ prolapse tend to occur in middle age, these are modifiable conditions that can be successfully treated and contribute to healthy aging and improved quality of life.


Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3741)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety measure to exclude possibility of cancer before proceeding with surgery. A cancer diagnosis would indicate a different approach to the surgery.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Being tested at individual and group practice level.

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to hysterectomy and can be referred to a gynecologic oncologist for appropriate staging and treatment for the malignancy. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). In a recent review of 63 robotic-assisted supracervical hysterectomies with sacrocervicopexies for pelvic organ prolapse, 2 patients (3.2%) were found on final pathology to have endometrial carcinoma.. Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.


Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3741)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to hysterectomy and can be referred to a gynecologic oncologist for appropriate staging and treatment for the malignancy. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). In a recent review of 63 robotic-assisted supracervical hysterectomies with sacrocervicopexies for pelvic organ prolapse, 2 patients (3.2%) were found on final pathology to have endometrial carcinoma.. Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.


Preoperative pessary for pelvic organ prolapse attempted for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3745)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GU. Unclear the benefit of two pessary measures (also X3750 pessary offered). Consider composite of both measures for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Fills a gap in measurement for GU.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No. Not currently in use.

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by involving specialties.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 38% (219/575) of patients actually tried a pessary with their surgeon before being operated on for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse attempted for program(s): MSSP (MUC ID: X3745)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 38% (219/575) of patients actually tried a pessary with their surgeon before being operated on for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse offered for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3750)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GU for alternative to surgery. Unclear the benefit of two pessary measures (also X3745 pessary attempted). Consider composite of both measures for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap in measurement for GU. Non-surgical alternative prior to surgery.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Measure promotes alignment by addressing gaps in specality measurement.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 77% (443/575) of surgeons offered their patients a pessary prior to surgery for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse offered for program(s): MSSP (MUC ID: X3750)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: Important clinician-only level measure. Does not relate to MSSP program objectives.

Does the measure address a critical program objective as defined by MAP? No. Narrow measure related to single condition. Does not relate to MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes.

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 77% (443/575) of surgeons offered their patients a pessary prior to surgery for pelvic organ prolapse.


Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3808)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Evidence-based, preoperative process of care measure. Additional measure for anesthesia.

Does the measure address a critical program objective as defined by MAP? Yes. Evidence-based treatment related to improved patient outcomes.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing for use in Hospital/Acute Care Facility, in beta testing.LOA Tested: Clinician: Individual; Clinician: Group/Practice; Clinician: Team; Facility

Is the measure currently in use? Yes. PQRS only.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Late stent thrombosis is a relatively rare but serious complication of stent placement, with an estimated case fatality rate of up to 45%. Multiple studies have shown that premature discontinuation of dual antiplatelet therapy is associated with increased risk of stent thrombosis in patients with drug-eluting stents. Late stent thrombosis, or thrombosis >1 year after stent placement, is of particular concern for drug-eluting stents. This concern indicates a need for a longer course of dual antiplatelet therapy for patients with drug-eluting stents compared to those with bare metal stents.


Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3808)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: While an important clinical measure, it does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.

Does the measure address a critical program objective as defined by MAP? Yes.  This process measure is an important preventive service; however, this measure does not encourage coordination or shared accountability across settings, providers, or time. ·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response:  This measure addresses an important preventive process for beneficiaries who may have a complication from a stent placement. Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: The measure does not address care delivered across care settings and providers.·        Promote alignment across other quality measurement reporting programs (e.g., end of life palliative care);·        Response: No.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: The measure does not address the high-value measurement domains identified by the MAP for the Medicare Shared Savings Program.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs. 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Late stent thrombosis is a relatively rare but serious complication of stent placement, with an estimated case fatality rate of up to 45%. Multiple studies have shown that premature discontinuation of dual antiplatelet therapy is associated with increased risk of stent thrombosis in patients with drug-eluting stents. Late stent thrombosis, or thrombosis >1 year after stent placement, is of particular concern for drug-eluting stents. This concern indicates a need for a longer course of dual antiplatelet therapy for patients with drug-eluting stents compared to those with bare metal stents.


Prescription of HIV Antiretroviral Therapy for program(s): MSSP (MUC ID: E2083)

Full Measure Specifications

NQF Number (if applicable): 2083

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression)

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Yes. Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? . Yes

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Prescription of HIV antiretroviral therapy is a critical component of the HIV care continuum. Although HIV viral suppression is the ultimate outcome of HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap-around supportive services within HIV care.


Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3806)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This process measure includes evaluation of risk for PONV and adminstration of appropriate preventive medications.

Does the measure address a critical program objective as defined by MAP? Yes. This measure satisfies a gap area in its' assessment of patients with post-operative nausea and vomiting (PONV) who receive combination therapy. This measure also promotes participation among eligible professionals.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is in use under: PQRS (Qualified Clinical Data Registry Option) then it should align with the established objectives for other PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk factors for PONV, demonstrated effective prophylactic regimes based on these risk factors, and demonstrated high variability in this outcome across individual centers and providers. Further, a number of papers have shown that performance can be assessed at the level of individual providers -- the outcome is common enough that sufficient power exists to assess variability and improvement at this level.


Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3806)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses an important area for potential surgical care improvement for Medicare beneficiaries.

Does the measure address a critical program objective as defined by MAP? Yes.  This measure seeks to improve the health of a specific segment of the Medicare FFS population, specifically thosewho undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.§ Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;o  Response: This measure seeks to improve the health of a specific segment of the Medicare FFS population, specifically thosewho undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: This measure does not address the rate of growth in health care spending.·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not address care across settings.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care);·        Response: This measure does promote alignment across PQRS-based programs.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This measure does not address the high value measurement areas identified by the MAP. There is insufficient evidence that assessment of nausea and vomiting is associated with fewer postoperative complications; however, is a standard of care that should be done during recovery[i].[i] https://www.asahq.org/For-Members/Practice-Management/~/media/For%20Members/Practice%20Management/PracticeParameters/2013/Practice%20Guidelines%20for%20Postanesthetic%20Care%202013.ashx

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program

Does the measure promote alignment and parsimony? Yes. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.  

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk factors for PONV, demonstrated effective prophylactic regimes based on these risk factors, and demonstrated high variability in this outcome across individual centers and providers. Further, a number of papers have shown that performance can be assessed at the level of individual providers -- the outcome is common enough that sufficient power exists to assess variability and improvement at this level.


Prevention Quality Indicators #90 (PQI #90) for program(s): MSSP (MUC ID: X3715)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Requires testing at ACO level. Need to consider appropriateness of conditions within composite for Medicare FFS population.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriate use measure for hospitalization. Not all conditions relevant for Medicare FFS population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Requires testing at ACO level

Is the measure currently in use? State level. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? Composite of multiple potentially avoidable hospitalizations.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Addresses prevention and is a composite with PQIs already in program.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): MSSP (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Population screening for alcohol dependence; support development for PRS and EHR Incentive also.

Does the measure address a critical program objective as defined by MAP? Yes. Screening for important condition in Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? Finalized Public Programs: Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Also support development for PQRS and EHR Incentive programs..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Recent NQF maintenance review reocmmends continued endorsement of this revised measure that now includes follow-up after a positive screen.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009. This measure is also duplicative of composite MUC X3475 as alcohol screening is one of the components.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening with follow-up measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. During NQF-endorsement review testing using automated EHR reports as well as through manual chart abstraction was reviewed. CMS has determined that all EHR measure are being updated to most current EHR specification standards.?

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure was tested at the ambulatory level.

Is the measure currently in use? Yes. An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009.

Does a review of its performance history raise any concerns? No. Recent data for mean performance of the measure is as follows:- 2009: 31.0% among 1,876 eligible professionals submitting- 2010: 63.2% among 4,635 eligible professionals submitting 

Does the measure promote alignment and parsimony? Yes. The abbreviated version of this measure is already in use in PQRS.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was evaluated by the Behavioral Health Steering Committee in 2014. The Committee agreed the the impact of screening and brief counseling on unhealthy alcohol use is well documented and that gaps in care exist. The Committee voted overwhelming

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): MUEP (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Complements existing population screening measure with broad appllicability.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Would fill a gap in an important screening topic area.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Recent NQF review and continued endorsement recommended.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Migraine Medication Prescribed for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3772)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate preventive treatment for patients with frequent migraines. Conditional on testing at the clincian-level and submission for NQF endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of appropriate preventive treatment for patients with frequent migraines.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: This measure is designed to address the strong gap in care in the use of prophylactic medication for migraine headache. Migraine is suboptimally treated in the majority of patients. Note: this measure does not specifically address chronic migraine or MRM.


Preventive Migraine Medication Prescribed for program(s): MSSP (MUC ID: X3772)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure is designed to address the strong gap in care in the use of prophylactic medication for migraine headache. Migraine is suboptimally treated in the majority of patients. Note: this measure does not specifically address chronic migraine or MRM.


Primary C-Section Rate 2014 for program(s): MSSP (MUC ID: X3768)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important measure. Not appropriate for Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Important appropriateness measure. Not relevant to Medicare FFS population

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The growing support for the claim that provider-dependent indications are contributing to the overall increase among cesareans can be seen from the results of two recent studies examining the drivers for the increase in cesarean deliveries. Barber et al. (2011) at Yale analyzed primary and repeat cesareans from 2003 to 2009. Among primary cesarean deliveries, more subjective indications (non-reassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions). Similarly, Getahun et al. (2009) examined the causes for the rise in cesarean deliveries among different racial and ethnic groups in Kaiser Permanente Southern California over the last 17 years. Their findings were similar to those from Yale. In a retrospective cohort study conducted by Ehrenthal et al. (2010), labor induction was associated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. This was more pronounced among a low-risk group of women without major complications. Beyond the medical burden to mothers and babies, the financial burden on payers is large: facility charges for cesarean are nearly twice that for vaginal delivery ($24,700 vs. $14,500). In California alone, the additional heath care costs to the system are conservatively estimated to be over $300 million annually (Main et al., 2011) The most frequent causes of severe maternal morbidity are obstetric hemorrhage (bleeding) and uterine infection. These are significantly more common with cesarean surgery and also represent the two leading causes of hospital readmission in the first 30 days post-delivery. A recent CDC analysis showed that the rate of severe obstetric hemorrhage has significantly increased (by 50%) over the last 15 years in the U.S. There has also been a 270% increase in blood transfusions, with both hemorrhage and transfusions correlated to the rise in cesarean deliveries. Infection is the most common serious complication of cesarean delivery with typical rates of 3 to 9% (Kuklina et al., 2009). The American College of Obstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate (ACOG, 2000).


Primary C-Section Rate 2014 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3768)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Outcome measure important to consumers in use in Minnesota. First public reports aredue in late 2014. Fills a gap in perinatal measures.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome; submitted by Consumer Purchaser Alliance; few current measure for obstetricians

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Piloted in MN for clinciain groups; recommended for use in state-wide reporting

Is the measure currently in use? Yes. Measure specifications and instructions for the program available at: http://mncm.org/wp-content/uploads/2014/05/C-section_Data_Collection_Guide_FINAL-5.8.2014.pdf 

Does a review of its performance history raise any concerns? No. No performance data - first public reporting due late 2014

Does the measure promote alignment and parsimony? Yes. Duplicate measure:X3788 (claims); 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF had endiorsed the hospital -level measure from the Joint Commission that is closely related to this measure.

Rationale for measure provided by HHS: The growing support for the claim that provider-dependent indications are contributing to the overall increase among cesareans can be seen from the results of two recent studies examining the drivers for the increase in cesarean deliveries. Barber et al. (2011) at Yale analyzed primary and repeat cesareans from 2003 to 2009. Among primary cesarean deliveries, more subjective indications (non-reassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions). Similarly, Getahun et al. (2009) examined the causes for the rise in cesarean deliveries among different racial and ethnic groups in Kaiser Permanente Southern California over the last 17 years. Their findings were similar to those from Yale. In a retrospective cohort study conducted by Ehrenthal et al. (2010), labor induction was associated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. This was more pronounced among a low-risk group of women without major complications. Beyond the medical burden to mothers and babies, the financial burden on payers is large: facility charges for cesarean are nearly twice that for vaginal delivery ($24,700 vs. $14,500). In California alone, the additional heath care costs to the system are conservatively estimated to be over $300 million annually (Main et al., 2011) The most frequent causes of severe maternal morbidity are obstetric hemorrhage (bleeding) and uterine infection. These are significantly more common with cesarean surgery and also represent the two leading causes of hospital readmission in the first 30 days post-delivery. A recent CDC analysis showed that the rate of severe obstetric hemorrhage has significantly increased (by 50%) over the last 15 years in the U.S. There has also been a 270% increase in blood transfusions, with both hemorrhage and transfusions correlated to the rise in cesarean deliveries. Infection is the most common serious complication of cesarean delivery with typical rates of 3 to 9% (Kuklina et al., 2009). The American College of Obstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate (ACOG, 2000).


Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3743)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on sumission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value adverse outcome measure. approximately 200,000 inpatient surgical procedures for prolapse are performed annually in US. 11- 19%  of women will undergo surgery for prolapse or incontinence by age 80 to 85 years. The incidence of urinary tract in

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? Yes. Measure is used in the Australian Council on Healthcare Standards

Does a review of its performance history raise any concerns? No. No performance data available

Does the measure promote alignment and parsimony? Yes. Measure promotes alignment by involving specialities in program participation.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgery for pelvic organ prolapse. It is critically important for surgeons who are performing these procedures to recognize and repair any bladder injury intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of bladder injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3743)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This importantoutcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed

Does the measure address a critical program objective as defined by MAP? Yes.  This safety-related outcome measure focuses on a common and possibly devastating pelvic surgery complication in the Meducare population. This measure is under review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i]. ·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: The measure does not address care across setting and providers.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This is an important outcome measure; however was not specifically identified as a high-value area of measurement for the Medicare Shared Savings program by the MAP. [i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and this measure is under review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.

Does a review of its performance history raise any concerns? .

Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgery for pelvic organ prolapse. It is critically important for surgeons who are performing these procedures to recognize and repair any bladder injury intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of bladder injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3744)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Adverse outcome measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The measure is currently being tested.

Is the measure currently in use? Yes. Used in the Australian Council on Healthcare Standards

Does a review of its performance history raise any concerns? No. Performance data unavailable

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by involving specalities in program reporting.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There are numerous approaches to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and robotic. The incidence of visceral injury ranges from 0.1-4% ( SGS Systemic Review  Obstet Gynecol 2008: 112: 1131-1142) depending on the approach with high potential for morbidity. Unrecognized injury to the intestine increases the risk of mortality from 2 to 23 % (Chapron et al.  J Am Coll Surg. 1991;185:461-465, Baggish, MS J Gynecol Surg. 2003;19:63-73). It is critically important for surgeons who are performing these procedures to recognize and repair any visceral injuries intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of visceral injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3744)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This important outcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed.

Does the measure address a critical program objective as defined by MAP? Yes.  This outcome measure focuses on a common and possibly devastating pelvic surgery complication. This measure isunder review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i]. Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: N/A·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This is an important outcome measure; however was not specifically identified as a high-value area of measurement for the Medicare Shared Savings program by the MAP.[i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and is under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.

Does a review of its performance history raise any concerns? .

Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There are numerous approaches to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and robotic. The incidence of visceral injury ranges from 0.1-4% ( SGS Systemic Review  Obstet Gynecol 2008: 112: 1131-1142) depending on the approach with high potential for morbidity. Unrecognized injury to the intestine increases the risk of mortality from 2 to 23 % (Chapron et al.  J Am Coll Surg. 1991;185:461-465, Baggish, MS J Gynecol Surg. 2003;19:63-73). It is critically important for surgeons who are performing these procedures to recognize and repair any visceral injuries intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of visceral injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3813)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Adverse outcome measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use by the Australian Council on Healthcare Standards.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. While there are currently no measures within PQRS that address the topic-are this measure covers, inclusion of this measure in the program could promote development of additional measures to evaluate ureter injuries related to pelvic organ prolapse repai

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Ureteral injury is an uncommon but potentially serious complication of surgery for pelvic organ prolapse. It is critically important for surgeons who are performing these procedures to recognize and repair any ureteral injuries intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of ureteric injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3813)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary:   Conditional Support pending NQF review and endorsement

Does the measure address a critical program objective as defined by MAP? Yes.  This outcome measure, which is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program, focuses on ureteral injury, a rare but possibly grave surgery complication for pelvic organ prolapse. ·        Critical Objectives·        Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;·        Response: This measure addresses an important area of measurement since prolapse repair is a common procedure with 100,000 to 200,000 surgeries performed per year. In addition to impacting a large number of individuals, the cost of treatment and rate of complications are high[i].·        Improve quality and health outcomes while lowering the rate of growth of healthcare spending;·        Response: N/A·        Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;·        Response: This measure does not address care delivered across care settings or multiple providers.·        Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;·        Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.·        Include more high-value measures such as: o  Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o  Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o  Measure of health risks with follow-up interventions; o  Cost and resource use measures; ando  Appropriate use measures.·        Response: This is an important outcome measure; however, it does not address high-value domains identified by the MAP for MSSP.  [i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and is under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.

Does a review of its performance history raise any concerns? .

Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Ureteral injury is an uncommon but potentially serious complication of surgery for pelvic organ prolapse. It is critically important for surgeons who are performing these procedures to recognize and repair any ureteral injuries intraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate of ureteric injury during pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of their surgical care.


Quality Of Life Assessment For Patients With Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3786)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient reported outcome measure for quality of life in patients with headaches. Conditional on testing at the clincian-level and submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Patient reported outcome measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Fully developed and tested.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure establishes an initial or baseline QoL score from which the patient should use the same QoL tool/questionnaire at least one additional time during the measurement period. The two assessments must be separated by at least 90 days for MIDAS and at least 4 weeks for any other tool. It is expected that the QoL score or ranking will stay the same or improve in order for this measure to be successfully completed.


Quality Of Life Assessment For Patients With Primary Headache Disorders for program(s): MSSP (MUC ID: X3786)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important PROM appropriate for clinician level measurement; may be too narrow for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Patient reported outcome measure for single condition.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure establishes an initial or baseline QoL score from which the patient should use the same QoL tool/questionnaire at least one additional time during the measurement period. The two assessments must be separated by at least 90 days for MIDAS and at least 4 weeks for any other tool. It is expected that the QoL score or ranking will stay the same or improve in order for this measure to be successfully completed.


Rate of surgical conversion from lower extremity endovascular revascularization procedure for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3754)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value adverse outcome measure for interventional radiologists.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, adverse outcome measure for interventioal radiologists.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Conversions from a planned lower extremity endovascular revascularization procedure to a surgical procedure indicates either poor patient assessment/procedural assignment, or procedural failure. This represents a patient care quality measure. Patients who undergo unplanned surgical conversion have a higher cost of care and higher morbidity and mortality. There is a higher expense for dual procedures, with use of endovascular tools and surgical procedural time and equipment, as well as longer length of stay and rehabilitation. Studies show higher rates of limb salvage in patients with foot ulcers after surgical or catheter based restoration of arterial blood flow than with medical therapy alone, but there is insufficient robust data to indicate better outcomes with endovascular or open bypass treatment of arterial insufficiency in this patient group. (1) Both amputation-free survival and quality of life outcomes have been shown to be comparable for patients with critical limb ischemia treated with either open bypass or endovascular repair, but the bypass-first strategy has been shown to be more costly. (2) There are many studies suggesting benefit of an endovascular-first approach to limb salvage because of the proposed patient benefits, including ability to avoid general anesthesia for these procedures, avoidance of a surgical incision and attendant healing time, shorter length of hospital stay with endovascular revascularization when compared to bypass, strong patient preference for endovascular approaches, and decreased cost of a successful endovascular approach. Although long term limb salvage outcomes are equivalent regardless of the initial strategy adopted, some data indicate a high rate of early technical failure of endovascular treatment of critical limb ischemia, but high secondary patency rates and high limb conservation rates in spite of initial technical failures, indicating that repeat procedures, both endovascular and open, tend to be successful in this patient group. A meta-analysis of 30 studies of below knee angioplasty showed a higher technical failure rate of endovascular treatment than that seen with open (bypass) repair. (3) This same meta-analysis reports that repeat procedures in patients with endovascular-first failures were more likely to be bypass procedures than repeated endovascular procedures. Another study of 1023 patients undergoing either endovascular or open surgical treatment for critical limb ischemia demonstrated a higher rate of secondary surgical procedures in the endovascular group compared with the surgical group, but again showed comparable 5 year limb salvage rates in the two groups. (4) Notably, it has been demonstrated that the difference in patency rates and differences in rates of conversion to bypass appear to be partly related to the specialty of the operator, based on studies of procedural failure and open conversion rates in different physician groups. Two large studies of extracted data, one of Medicare claims data assessing mortality, transfusion rates, intensive care unit use, length of stay, and subsequent repeat revascularization procedures or amputation (5), and one of National Inpatient Sample (NIS) data reviewing in-hospital mortality and iatrogenic arterial injuries (6), showed statistically significant differences in outcomes across physician groups. One of these studies (Zafar, et al) suggested that there may be a higher use of repeat intervention, including adjunctive, unplanned surgical bypass, and a higher rate of amputation following a primary endovascular procedure in some physician cohorts. The reasons for this discrepancy are unclear, and may represent patient selection, operator bias towards endovascular revascularization in all comers, technical ability, or other factors. The newly-approved NHLBI trial, Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia, proposes to look at outcomes, including open conversions and amputations, in a cohort of patients randomized to open vs endovascular therapy. This trial will be multidisciplinary, evaluating all specialists involved in procedural care of this group of patients, and will ultimately provide guidance for physicians in terms of patient assignment to open vs endovascular care, and will establish solid data to support thresholds for conversion and amputation. However, data will not be available for years to come. This measure proposes, based on the data available in the existing literature, to track use of repeat or unplanned adjunctive surgical (bypass or amputation) procedures in patients undergoing revascularization procedures for lower extremity arterial insufficiency. It is expected that this rate should be equivalent across all physician groups performing endovascular procedures when adjusted for specific patient risk factors. With establishment of a baseline benchmark rate for conversion to surgical therapy based on existing data from the Medicare sample, rates of conversion may be tracked to encourage appropriate patient selection or referral to expert operators to improve patient outcomes and reduce excessive resource use by selection of the most appropriate procedure and procedural operator. 1. Hinchliffe RJ et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metabolism Research and Reviews 2012; 28(Suppl. 1):179-217. 2. Adam DJ et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet 2005;366:1925-34. 3. Romiti M, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975-81. 4. Söderström MI et al. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis. Annals of Surgery 2010;252:765-773. 5. Zafar AM et al. Lower-Extremity Endovascular Interventions for Medicare Beneficiaries: Comparative Effectiveness as a Function of Provider Specialty, J Vasc Interv Radiol 2012; 23:3–9. 6. Eslami MH et al. Peripheral arterial interventions: Trends in market share and outcomes by specialty, 1998-2005; J Vasc Surg 2009;50:1071-8.


Rate of surgical conversion from lower extremity endovascular revascularization procedure for program(s): MSSP (MUC ID: X3754)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Conversions from a planned lower extremity endovascular revascularization procedure to a surgical procedure indicates either poor patient assessment/procedural assignment, or procedural failure. This represents a patient care quality measure. Patients who undergo unplanned surgical conversion have a higher cost of care and higher morbidity and mortality. There is a higher expense for dual procedures, with use of endovascular tools and surgical procedural time and equipment, as well as longer length of stay and rehabilitation. Studies show higher rates of limb salvage in patients with foot ulcers after surgical or catheter based restoration of arterial blood flow than with medical therapy alone, but there is insufficient robust data to indicate better outcomes with endovascular or open bypass treatment of arterial insufficiency in this patient group. (1) Both amputation-free survival and quality of life outcomes have been shown to be comparable for patients with critical limb ischemia treated with either open bypass or endovascular repair, but the bypass-first strategy has been shown to be more costly. (2) There are many studies suggesting benefit of an endovascular-first approach to limb salvage because of the proposed patient benefits, including ability to avoid general anesthesia for these procedures, avoidance of a surgical incision and attendant healing time, shorter length of hospital stay with endovascular revascularization when compared to bypass, strong patient preference for endovascular approaches, and decreased cost of a successful endovascular approach. Although long term limb salvage outcomes are equivalent regardless of the initial strategy adopted, some data indicate a high rate of early technical failure of endovascular treatment of critical limb ischemia, but high secondary patency rates and high limb conservation rates in spite of initial technical failures, indicating that repeat procedures, both endovascular and open, tend to be successful in this patient group. A meta-analysis of 30 studies of below knee angioplasty showed a higher technical failure rate of endovascular treatment than that seen with open (bypass) repair. (3) This same meta-analysis reports that repeat procedures in patients with endovascular-first failures were more likely to be bypass procedures than repeated endovascular procedures. Another study of 1023 patients undergoing either endovascular or open surgical treatment for critical limb ischemia demonstrated a higher rate of secondary surgical procedures in the endovascular group compared with the surgical group, but again showed comparable 5 year limb salvage rates in the two groups. (4) Notably, it has been demonstrated that the difference in patency rates and differences in rates of conversion to bypass appear to be partly related to the specialty of the operator, based on studies of procedural failure and open conversion rates in different physician groups. Two large studies of extracted data, one of Medicare claims data assessing mortality, transfusion rates, intensive care unit use, length of stay, and subsequent repeat revascularization procedures or amputation (5), and one of National Inpatient Sample (NIS) data reviewing in-hospital mortality and iatrogenic arterial injuries (6), showed statistically significant differences in outcomes across physician groups. One of these studies (Zafar, et al) suggested that there may be a higher use of repeat intervention, including adjunctive, unplanned surgical bypass, and a higher rate of amputation following a primary endovascular procedure in some physician cohorts. The reasons for this discrepancy are unclear, and may represent patient selection, operator bias towards endovascular revascularization in all comers, technical ability, or other factors. The newly-approved NHLBI trial, Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia, proposes to look at outcomes, including open conversions and amputations, in a cohort of patients randomized to open vs endovascular therapy. This trial will be multidisciplinary, evaluating all specialists involved in procedural care of this group of patients, and will ultimately provide guidance for physicians in terms of patient assignment to open vs endovascular care, and will establish solid data to support thresholds for conversion and amputation. However, data will not be available for years to come. This measure proposes, based on the data available in the existing literature, to track use of repeat or unplanned adjunctive surgical (bypass or amputation) procedures in patients undergoing revascularization procedures for lower extremity arterial insufficiency. It is expected that this rate should be equivalent across all physician groups performing endovascular procedures when adjusted for specific patient risk factors. With establishment of a baseline benchmark rate for conversion to surgical therapy based on existing data from the Medicare sample, rates of conversion may be tracked to encourage appropriate patient selection or referral to expert operators to improve patient outcomes and reduce excessive resource use by selection of the most appropriate procedure and procedural operator. 1. Hinchliffe RJ et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metabolism Research and Reviews 2012; 28(Suppl. 1):179-217. 2. Adam DJ et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet 2005;366:1925-34. 3. Romiti M, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975-81. 4. Söderström MI et al. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis. Annals of Surgery 2010;252:765-773. 5. Zafar AM et al. Lower-Extremity Endovascular Interventions for Medicare Beneficiaries: Comparative Effectiveness as a Function of Provider Specialty, J Vasc Interv Radiol 2012; 23:3–9. 6. Eslami MH et al. Peripheral arterial interventions: Trends in market share and outcomes by specialty, 1998-2005; J Vasc Surg 2009;50:1071-8.


Risky Behavior Assessment or Counseling by Age 13 Years for program(s): MUEP (MUC ID: E1406)

Full Measure Specifications

NQF Number (if applicable): 1406

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Suggest broadening the age range and combing this measure with E1507 Risky Behavior Assessment or Counseling by age 18 years.

Does the measure address a critical program objective as defined by MAP? Yes. Additional measure for specialists in adolescent care.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. The non-EHR measure was endorsed by NQF but the steward has retired it due to lack of use.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Non-EHR measure retired from endorsement by the steward due to lack of use.

Rationale for measure provided by HHS: NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment or counseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessment or Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity. Early alcohol and drug use (pre-adolescent/early adolescent) is a predictor of later dependence. In the 2003 National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15 were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately 58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s. Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral Health Coordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reports separate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 the BHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is more likely to see their doctor without their parent, which promotes more honest conversations. References: 2010-2011 National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm


Risky Behavior Assessment or Counseling by Age 18 Years for program(s): MUEP (MUC ID: E1507)

Full Measure Specifications

NQF Number (if applicable): 1507

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Suggest broadening the age range and combining with measure E1406 for parsimony.

Does the measure address a critical program objective as defined by MAP? Yes. Addiitonal measure for specialists in adolescent care.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Non-EHR measure retired by the steward for lack of use.

Does the measure promote alignment and parsimony? No. Would combine with measure under consideration E1406 for parsimony.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Non-EHR measure was endorsed, but has been retired by the measure steward for lack of use.

Rationale for measure provided by HHS: NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment or counseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessment or Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity. Early alcohol and drug use (pre-adolescent/early adolescent) is a predictor of later dependence. In the 2003 National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15 were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately 58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s. Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral Health Coordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reports separate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 the BHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is more likely to see their doctor without their parent, which promotes more honest conversations. References: 2010-2011 National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm


Scoliosis Evaluation Ordered for program(s): MSSP (MUC ID: X3798)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is a risk of evolving musculoskeletal spine deformities, such as scoliosis, kyphosis, or rigid spine syndrome, in various dystrophies. These musculoskeletal deformities can result in discomfort and functional impairment, interfering with gait, activities of daily living, and pulmonary function. The proper management of musculoskeletal spine deformities is important in order to reduce discomfort, preserve mobility or ability to sit in a wheelchair, and reduce pulmonary complications.


Scoliosis Evaluation Ordered for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3798)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Scoliosis, or spinal curvature, is common in patients with Duchenne's muscular dystrophy. Early detection and surgery can aid breathing, lessen back pain and improve sitting balance. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in the measurement of specialty care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. Not in use in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of specality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is a risk of evolving musculoskeletal spine deformities, such as scoliosis, kyphosis, or rigid spine syndrome, in various dystrophies. These musculoskeletal deformities can result in discomfort and functional impairment, interfering with gait, activities of daily living, and pulmonary function. The proper management of musculoskeletal spine deformities is important in order to reduce discomfort, preserve mobility or ability to sit in a wheelchair, and reduce pulmonary complications.


Spine Fusion/ Refusion Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0353)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measure are needed for spine surgery to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures required for VBPM.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft report for the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed Recommendations for Evaluating Episode Groupers.” (2014) Available at http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406-1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf).  Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3003, 124 Stat. 366 (2010)).


Statin Therapy for the Prevention and Treatment of Cardiovascular Disease for program(s): MUEP (MUC ID: X3729)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk for all adults aged >=21 years is essential to not only prevent ASCVD but also to reduce ASCVD events for those individuals with a current diagnosis. The new guidelines: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines” published in Circulation in November, 2013, focuses on those most likely to benefit from evidence-based statin medication therapy to reduce ASCVD risk. LDL-C treatment goals or targets are not the focus of treatment as in the past.


Statin Therapy for the Prevention and Treatment of Cardiovascular Disease for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3729)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The measure conforms to new guidelines for statin use and should replace prior measures based on old guidelines.

Does the measure address a critical program objective as defined by MAP? Yes. Conforms to new guidelines for statin use.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Measure is specified at the individual and group practice levels but could be tested at the clinician level.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. Measure is not fully tested, so there are no results to draw conclusions from in the context of alignment assessment.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk for all adults aged >=21 years is essential to not only prevent ASCVD but also to reduce ASCVD events for those individuals with a current diagnosis. The new guidelines: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines” published in Circulation in November, 2013, focuses on those most likely to benefit from evidence-based statin medication therapy to reduce ASCVD risk. LDL-C treatment goals or targets are not the focus of treatment as in the past.


Statin Therapy for the Prevention and Treatment of Cardiovascular Disease for program(s): MSSP (MUC ID: X3729)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High priority area. Meets program objective for risk assessment and intervention.

Does the measure address a critical program objective as defined by MAP? Yes. High priority risk assessment and treatment for Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Measure could be appropriate across wide range of programs.. No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk for all adults aged >=21 years is essential to not only prevent ASCVD but also to reduce ASCVD events for those individuals with a current diagnosis. The new guidelines: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines” published in Circulation in November, 2013, focuses on those most likely to benefit from evidence-based statin medication therapy to reduce ASCVD risk. LDL-C treatment goals or targets are not the focus of treatment as in the past.


Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting for program(s): MUEP (MUC ID: X4007)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current alcohol dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? . Several existing substance use screening and intervention measures. Harmonization and consolidation and alignment with PQRS is indicated.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Research has shown that among patients diagnosed with alcohol dependence, only 4.64% were referred for psychosocial treatment in the form of substance abuse counseling, inpatient rehabilitation programs, outpatient rehabilitation programs, or mutual help groups. While pharmacologic therapy has established efficacy, often in combination with psychosocial therapy, in promoting abstinence and preventing relapse in alcohol-dependent patients, physician rates of prescribing pharmacologic therapy for alcohol dependence are also considerably low. A recent study found that these low rates prevail even among addiction medicine physicians who prescribed naltrexone to only 13% of their alcohol dependent patients. Pharmacotherapy and psychosocial treatment should be routinely considered for all patients with alcohol dependence, and patients should be informed of this option. The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines (from the American Psychiatric Association [APA]) and represent the evidence base for the measure: Psychosocial treatments found effective for some patients with an alcohol use disorder include motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), behavioral therapies, 12-step facilitation (TSF), marital and family therapies, group therapies, and psychodynamic therapy/interpersonal therapy (IPT). (APA, 2006) Specific pharmacotherapies for alcohol-dependent patients have well-established efficacy and moderate effectiveness: • Naltrexone may attenuate some of the reinforcing effects of alcohol, although data on its long-term efficacy are limited. The use of long-acting, injectable naltrexone may promote adherence, but published research is limited and FDA approval is pending. [Note: Extended-release naltrexone for injection has since received FDA approval] • Acamprosate, a gamma-aminobutyric acid (GABA) analog that may decrease alcohol craving in abstinent individuals, may also be an effective adjunctive medication in motivated patients who are concomitantly receiving psychosocial treatment. • Disulfiram is an effective adjunct to a comprehensive treatment program for reliable, motivated patients whose drinking may be triggered by events that suddenly increase alcohol craving. (APA, 2006) Empirically validated psychosocial treatment interventions should be initiated for all patients with substance use illnesses. Pharmacotherapy should be offered and available to all adult patients diagnosed with alcohol dependence and without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with psychosocial treatment/support. (National Quality Forum [NQF], 2007) EVIDENCE FOR RATIONALE: American Psychiatric Association (APA), Physician Consortium for Performance Improvement® (PCPI), National Committee for Quality Assurance (NCQA). Substance use disorders physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Jul. 22 p. [11 references] American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders. 2nd ed. Washington (DC): American Psychiatric Association (APA); 2006 Aug. 275 p. [1789 references] Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor-quality health care. N Engl J Med. 2006 Mar 16;354(11):1147-56. [32 references] PubMed Mark TL, Kranzler HR, Song X. Understanding US addiction physicians' low rate of naltrexone prescription. Drug Alcohol Depend. 2003 Sep 10;71(3):219-28. PubMed National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment practices; a consensus report. Washington (DC): National Quality Forum; 2007.


Substance use disorders: 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 for program(s): MUEP (MUC ID: X4208)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current opioid dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.  Multiple substance use screening and intervention -- harmonization and consolidation is indicated.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Methadone and buprenorphine, in combination with psychosocial treatment, are effective in reducing drug use and supporting treatment retention. Until recently, their use had been limited due to regulatory requirements with capacity at approved facilities only able to meet the treatment needs of 15% of opioid dependent individuals. While the increased access to opioid agonist treatments has resulted in an increase in their use, a large number of clinicians have yet to gain eligibility to prescribe the appropriate medications. Moreover, among physicians with waivers to prescribe buprenorphine, 33% were not actively prescribing. Pharmacotherapy and psychosocial treatment should be routinely considered for all patients with opioid addiction, and patients should be informed of this option. The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: Empirically validated psychosocial treatment interventions should be initiated for all patients with substance use illnesses. (National Quality Forum [NQF]) Pharmacotherapy should be recommended and available to all adult patients diagnosed with opioid dependence and without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with psychosocial treatment/support. (NQF) • Maintenance treatment with methadone or buprenorphine is appropriate for patients with a prolonged history (greater than 1 year) of opioid dependence. (American Psychiatric Association [APA]) • Maintenance treatment with naltrexone is an alternative strategy, although the utility of this strategy is often limited by lack of patient adherence and low treatment retention. (APA) Psychosocial treatments are effective components of a comprehensive treatment plan for patients with an opioid use disorder. Behavioral therapies (e.g., contingency management), cognitive behavioral therapies (CBTs), psychodynamic psychotherapy, and group and family therapies have been found to be effective for some patients with an opioid use disorder. (APA) Note: Federal and state regulations govern the use of methadone, levo-alpha-acetylmethadol (LAAM), and buprenorphine, the three opioids approved by the FDA for the treatment of opioid dependence. (APA) [Note: since the publication of the APA practice guideline, LAAM is no longer available in the United States for agonist maintenance treatment.] The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine issued a consensus statement to recognize and recommend definitions related to the use of opioids for the treatment of pain. They are as follows: • Addiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. • Physical Dependence: Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. • Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of opioid misuse that may involve any or all of the following: • Use of prescription opioids in an unapproved or inappropriate manner (such as cutting time-release preparations, injecting oral formulations, and applying fentanyl topical patches to oral or rectal mucosa) • Obtaining opioids outside of medical settings • Concurrent abuse of alcohol or illicit drugs • Repeated requests for dose increases or early refills, despite the presence of adequate analgesia • Multiple episodes of prescription "loss" • Repeatedly seeking prescriptions from other clinicians or from emergency rooms without informing prescriber, or after warnings to desist • Evidence of deterioration in the ability to function at work, in the family, or socially, which appears to be related to drug use • Repeated resistance to changes in therapy despite clear evidence of adverse physical or psychological effects from the drug • Positive urine drug screen—other substance use (cocaine, opioids, amphetamines or alcohol) • Meets DSM IV criteria for dependence on opioids (VA/DoD) EVIDENCE FOR RATIONALE: American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine; 2006. American Psychiatric Association (APA), Physician Consortium for Performance Improvement® (PCPI), National Committee for Quality Assurance (NCQA). Substance use disorders physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Jul. 22 p. [11 references] American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders. 2nd ed. Washington (DC): American Psychiatric Association (APA); 2006 Aug. 275 p. [1789 references] Merrill JO. Policy progress for physician treatment of opiate addiction. J Gen Intern Med. 2002 May;17(5):361-8. PubMed National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment practices; a consensus report. Washington (DC): National Quality Forum; 2007. Substance Abuse and Mental Health Services Administration. The determinations report: a report on the Physician Waiver Program established by the Drug Addiction Treatment Act of 2000 (DATA). Rockville (MD): Substance Abuse and Mental Health Services Administration; 2006 Mar 30. 8 p. [4 references] U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Rockville (MD): U.S. Preventive Services Task Force (USPSTF); 2002. 13 p. [13 references] Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of opioid therapy for chronic pain. Washington (DC): Veterans Health Administration, Department of Defense; 2003 Mar.


Substance Use Screening and Intervention Composite for program(s): MSSP (MUC ID: X3475)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important area of focus; new eMeasure.

Does the measure address a critical program objective as defined by MAP? Yes. Substance use screening with follow-up high priority

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Composite measure captures multiple health risks in single measure..

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure approved for trial use

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Substance use problems and illnesses have substantial impact on health and societal costs, and often are linked to catastrophic personal consequences. In 2010, an estimated 19.3% (45.3 million) of U.S. adults were current cigarette smokers; of these, 78.2% smoked every day, and 21.8% smoked some days. 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. In 2010, an estimated 22.6 million Americans aged 12 or older (~8.9 percent of the population) were current illicit drug users, which means they had used an illicit drug during the month prior to the survey. About 1 in 5 Americans aged 18?25 used illicit drugs in the past. Because many patients will not self-identify or have not yet developed detectable problems associated with substance use, screening can identify patients for whom intervention may be indicated. Brief motivational counseling for these various substances has been shown to be an effective treatment for reducing problem use, particularly in primary care settings. The 2011 National Survey on Drug Use and Health found that 1 in 20 persons in the U.S. aged 12 or older reported nonmedical use of prescription pain killers in the past year. Prescription drug overdose is now the leading cause of accidental death in the United States - surpassing motor vehicle accidents. Many scientific studies have also shown there are dire health consequences from untreated substance use disorders on medical complications of diabetes mellitus and other co-occurring chronic conditions. Substance use disorders (SUD) is one of the 10 categories of essential health benefits which the ACA requires most private insurers to cover. Insurers also must ensure these benefits comply with the Mental Health Parity and Addiction Equity Act of 2008. Consequently, it is necessary that health care providers in general medical settings be equipped with an appropriate training and resources as well as CMS 'meaningful use' reimbursement incentives, to support and guide science-based screening and counseling for substance use disorders in primary care, utilizing relevant electronic-health-record-based performance measures and accompanying evidence-based clinical decision support tools.


Substance Use Screening and Intervention Composite for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3475)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This composite eMeasure has been approved by NQF for the eMeasure Trial Use pilot.

Does the measure address a critical program objective as defined by MAP? Yes. This measure is a composite eMeasure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. If this is measure #2597, then it has not yet been fully tested and would have to be reviewed using the MUD pathway.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Recommended by the current NQF Behavioral Health Committee for continued testing as a trial eMeasure.

Rationale for measure provided by HHS: Substance use problems and illnesses have substantial impact on health and societal costs, and often are linked to catastrophic personal consequences. In 2010, an estimated 19.3% (45.3 million) of U.S. adults were current cigarette smokers; of these, 78.2% smoked every day, and 21.8% smoked some days. 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. In 2010, an estimated 22.6 million Americans aged 12 or older (~8.9 percent of the population) were current illicit drug users, which means they had used an illicit drug during the month prior to the survey. About 1 in 5 Americans aged 18?25 used illicit drugs in the past. Because many patients will not self-identify or have not yet developed detectable problems associated with substance use, screening can identify patients for whom intervention may be indicated. Brief motivational counseling for these various substances has been shown to be an effective treatment for reducing problem use, particularly in primary care settings. The 2011 National Survey on Drug Use and Health found that 1 in 20 persons in the U.S. aged 12 or older reported nonmedical use of prescription pain killers in the past year. Prescription drug overdose is now the leading cause of accidental death in the United States - surpassing motor vehicle accidents. Many scientific studies have also shown there are dire health consequences from untreated substance use disorders on medical complications of diabetes mellitus and other co-occurring chronic conditions. Substance use disorders (SUD) is one of the 10 categories of essential health benefits which the ACA requires most private insurers to cover. Insurers also must ensure these benefits comply with the Mental Health Parity and Addiction Equity Act of 2008. Consequently, it is necessary that health care providers in general medical settings be equipped with an appropriate training and resources as well as CMS 'meaningful use' reimbursement incentives, to support and guide science-based screening and counseling for substance use disorders in primary care, utilizing relevant electronic-health-record-based performance measures and accompanying evidence-based clinical decision support tools.


Substance Use Screening and Intervention Composite for program(s): MUEP (MUC ID: X3475)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Substance use problems and illnesses have substantial impact on health and societal costs, and often are linked to catastrophic personal consequences. In 2010, an estimated 19.3% (45.3 million) of U.S. adults were current cigarette smokers; of these, 78.2% smoked every day, and 21.8% smoked some days. 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. In 2010, an estimated 22.6 million Americans aged 12 or older (~8.9 percent of the population) were current illicit drug users, which means they had used an illicit drug during the month prior to the survey. About 1 in 5 Americans aged 18?25 used illicit drugs in the past. Because many patients will not self-identify or have not yet developed detectable problems associated with substance use, screening can identify patients for whom intervention may be indicated. Brief motivational counseling for these various substances has been shown to be an effective treatment for reducing problem use, particularly in primary care settings. The 2011 National Survey on Drug Use and Health found that 1 in 20 persons in the U.S. aged 12 or older reported nonmedical use of prescription pain killers in the past year. Prescription drug overdose is now the leading cause of accidental death in the United States - surpassing motor vehicle accidents. Many scientific studies have also shown there are dire health consequences from untreated substance use disorders on medical complications of diabetes mellitus and other co-occurring chronic conditions. Substance use disorders (SUD) is one of the 10 categories of essential health benefits which the ACA requires most private insurers to cover. Insurers also must ensure these benefits comply with the Mental Health Parity and Addiction Equity Act of 2008. Consequently, it is necessary that health care providers in general medical settings be equipped with an appropriate training and resources as well as CMS 'meaningful use' reimbursement incentives, to support and guide science-based screening and counseling for substance use disorders in primary care, utilizing relevant electronic-health-record-based performance measures and accompanying evidence-based clinical decision support tools.


TOTAL PER CAPITA COST MEASURE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES for program(s): MSSP (MUC ID: X2147)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Meet MSSP programmatic objectives. Support pending submission of revised measure to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Focus on lower rate of growth of Medicare expenditures. Focus across providers and settings of care.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Addresses gap in cost/resource use and aligns with VM


Unnecessary Screening Colonoscopy in Older Adults for program(s): MSSP (MUC ID: X3769)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important overuse measure for common screening test. Need to reconcile across competing colonoscopy overuse measure (including X3758).

Does the measure address a critical program objective as defined by MAP? Yes. Overuse of important screening test.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Colorectal cancer is the third most common malignancy and the second leading cause of cancer-related deaths in the United States. The lifetime risk of being diagnosed with cancer in the colon or rectum is about 5 percent. The percentage of new cases is higher in people from 65-84 years of age; the median age of diagnosis is 69 (NCI, 2013). The overall incidence by age for both men and women are as follows: • 4 percent between 35 and 44 years • 13.8 percent between 45 and 54 years • 20.8 percent between 55 and 64 years • 24 percent between 65 and 74 years • 24.1 percent between 75 and 84 years • 12 percent in 85 years and older The incidence of mortality rates for colorectal cancer are about 35 percent – 40 percent higher in men than in women,; however, both rates have decreased significantly since 1975 (ACS, 2013). The incidence rate declined from 60 cases to 45 cases per 100,000 people, and the mortality rate declined from 28 deaths to 17 deaths per 100,000 people (NCI, 2013). Declines in the incidence and mortality rates are due, in part, to the routine performance of preventive screening: improved screening is responsible for half of the observed reduction in both rates, while the remaining half derives from changes in the population prevalence of contributing risk factors (NCI, 2013). Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). This is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365). The charge for a colonoscopy can range from $1,000-$3,000; Medicare reimbursement covers 75 percent – 80 percent of charges. Based on the 2011 U.S. Census, there are currently 8.1 million individuals 85 and older in the U.S. Given this count, regular performance of colonoscopies among this population could result in significant health care spending (not including downstream costs due to subsequent clinical complications)(Goodwin, 2011). The population of individuals 85 years and older is projected to double by 2050; hence, the financial burden related to potentially inappropriate performance of colorectal screening can be expected to increase (Goodwin, 2011). CLINICAL RECOMMENDATION STATEMENTS : The USPTF (2008) recommends three screening regimens for individuals 50-75 years of age with average risk: • Annual high-sensitivity FOBT. • Sigmoidoscopy every 5 years, combined with high-sensitivity fecal occult blood testing every 3 years. • Optical colonoscopy every 10 years. For individuals from 76-85 years of age, the Task Force recommends against routine performance of screening unless individuals have not been previously screened, in which case it should be considered in the context of health status and competing risks for each individual (USPTF, 2008). For individuals older than 85 years, the Task Force recommends against screening when comparing overall benefits to harms (D Recommendation)(USPTF, 2008). The Task Force based these recommendations on a systematic review of the literature, supplemented with modeling data (USPTF, 2008; NCI 2013; USCR, 2011). For this subgroup, the Task Force concluded that the utility of screening is limited, given the time it takes for a polyp to develop into a clinically observable malignancy (10-26 years)(USPTF, 2008; NCI 2013; UCSR 2011). Moreover, individuals older than 85 are likely to have multiple comorbidities that influence any potential life-year gain (USPTF, 2008; NCI 2013; UCSR, 2011). They are also at increased risk of suffering from adverse events related to performance of a colonoscopy, with the rate of adverse events being 2.8 per 1,000 procedures and increased by seven-fold if a polypectomy is performed (USPTF, 2008; CDC 2012, NCI, 2013).


Unnecessary Screening Colonoscopy in Older Adults for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3769)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Appropriate use measure; duplication of X3758. Harmonization and consolidation to a single measure is needed. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: appropriate use

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. No testing data.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? Yes. Currently in use in AGA's Digestive Health Recognition Program.

Does a review of its performance history raise any concerns? No. No performance data.

Does the measure promote alignment and parsimony? Yes. This measure is used in comercial health plans in HEDIS. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Colorectal cancer is the third most common malignancy and the second leading cause of cancer-related deaths in the United States. The lifetime risk of being diagnosed with cancer in the colon or rectum is about 5 percent. The percentage of new cases is higher in people from 65-84 years of age; the median age of diagnosis is 69 (NCI, 2013). The overall incidence by age for both men and women are as follows: • 4 percent between 35 and 44 years • 13.8 percent between 45 and 54 years • 20.8 percent between 55 and 64 years • 24 percent between 65 and 74 years • 24.1 percent between 75 and 84 years • 12 percent in 85 years and older The incidence of mortality rates for colorectal cancer are about 35 percent – 40 percent higher in men than in women,; however, both rates have decreased significantly since 1975 (ACS, 2013). The incidence rate declined from 60 cases to 45 cases per 100,000 people, and the mortality rate declined from 28 deaths to 17 deaths per 100,000 people (NCI, 2013). Declines in the incidence and mortality rates are due, in part, to the routine performance of preventive screening: improved screening is responsible for half of the observed reduction in both rates, while the remaining half derives from changes in the population prevalence of contributing risk factors (NCI, 2013). Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). This is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365). The charge for a colonoscopy can range from $1,000-$3,000; Medicare reimbursement covers 75 percent – 80 percent of charges. Based on the 2011 U.S. Census, there are currently 8.1 million individuals 85 and older in the U.S. Given this count, regular performance of colonoscopies among this population could result in significant health care spending (not including downstream costs due to subsequent clinical complications)(Goodwin, 2011). The population of individuals 85 years and older is projected to double by 2050; hence, the financial burden related to potentially inappropriate performance of colorectal screening can be expected to increase (Goodwin, 2011). CLINICAL RECOMMENDATION STATEMENTS : The USPTF (2008) recommends three screening regimens for individuals 50-75 years of age with average risk: • Annual high-sensitivity FOBT. • Sigmoidoscopy every 5 years, combined with high-sensitivity fecal occult blood testing every 3 years. • Optical colonoscopy every 10 years. For individuals from 76-85 years of age, the Task Force recommends against routine performance of screening unless individuals have not been previously screened, in which case it should be considered in the context of health status and competing risks for each individual (USPTF, 2008). For individuals older than 85 years, the Task Force recommends against screening when comparing overall benefits to harms (D Recommendation)(USPTF, 2008). The Task Force based these recommendations on a systematic review of the literature, supplemented with modeling data (USPTF, 2008; NCI 2013; USCR, 2011). For this subgroup, the Task Force concluded that the utility of screening is limited, given the time it takes for a polyp to develop into a clinically observable malignancy (10-26 years)(USPTF, 2008; NCI 2013; UCSR 2011). Moreover, individuals older than 85 are likely to have multiple comorbidities that influence any potential life-year gain (USPTF, 2008; NCI 2013; UCSR, 2011). They are also at increased risk of suffering from adverse events related to performance of a colonoscopy, with the rate of adverse events being 2.8 per 1,000 procedures and increased by seven-fold if a polypectomy is performed (USPTF, 2008; CDC 2012, NCI, 2013).


Use of Imaging Studies for Low Back Pain for program(s): MSSP (MUC ID: E0052)

Full Measure Specifications

NQF Number (if applicable): 0052

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Measures applies to ages 18-50 years. Not applicable to the Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Denominator is specified for patient 18-50 years of age. Does not apply to the Medicare population.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Tested at health plan level.

Is the measure currently in use? Yes. Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: HEDIS; Wellpoint; Cigna; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? .

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Recent NQF review did not recommend the measure for continued endorsement. NQF did not consider EHR specifications.

Rationale for measure provided by HHS: Aligns with PQRS


Use of Multiple Concurrent Antipsychotics in Children and Adolescents for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3472)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is a patient safety and appropriate use measure for children and adolescents.  It is also important to dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Is is a patient safety and appropriateuse measure for children and adolescents.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Although there is little empirical evidence to support its use, the use of multiple concurrent antipsychotics is becoming an increasingly frequent practice in the mental health treatment of youth. One study of a large state Medicaid fee-for-service program found that 7 percent of children age 6-17 on any antipsychotic were prescribed two or more antipsychotics for longer than 60 days (Constantine et al., 2010). As of September 1, 2011, 4.1 percent of youth under age 18 in the New York State Medicaid behavioral health population on any antipsychotic were on two or more antipsychotics for longer than 90 days. Risks of multiple concurrent antipsychotics in comparison to monotherapy have not been systematically investigated; existing evidence appears largely in case reports, and includes increased risk of serious drug interactions, delirium, serious behavioral changes, cardiac arrhythmias, and death (Safer, Zito, & DosReis, 2003). None of the 10 AACAP practice parameters recommended concurrent use of multiple antipsychotic medications. The AACAP Practice Parameters for the Use of Atypical Antipsychotic Medications in Children and Adolescents states, “the use of multiple AAAs [atypical antipsychotics] has not been studied rigorously and generally should be avoided.” The Texas Psychotropic Medication Utilization Parameters for Foster Children includes “two or more concomitant antipsychotic medications” as a situation that “suggests the need for additional review of a patient’s clinical status.” Constantine RJ, Boaz T, Tandon R. (2010). Antipsychotic polypharmacy in the treatment of children and adolescents in the fee-for-service component of a large state Medicaid program. Clinical therapeutics, 32, 949-959. Safer, D.J., J.M. Zito, and S. DosReis, Concomitant psychotropic medication for youths. Am J Psychiatry, 2003. 160(3): p. 438-49. AACAP Practice Parameters for the Use of Atypical Antipsychotic Medications in Children and Adolescents 2010 Texas Psychotropic Medication Utilization Parameters for Foster Children.


Use of Multiple Concurrent Antipsychotics in Children and Adolescents for program(s): MUEP (MUC ID: X3472)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use?

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Although there is little empirical evidence to support its use, the use of multiple concurrent antipsychotics is becoming an increasingly frequent practice in the mental health treatment of youth. One study of a large state Medicaid fee-for-service program found that 7 percent of children age 6-17 on any antipsychotic were prescribed two or more antipsychotics for longer than 60 days (Constantine et al., 2010). As of September 1, 2011, 4.1 percent of youth under age 18 in the New York State Medicaid behavioral health population on any antipsychotic were on two or more antipsychotics for longer than 90 days. Risks of multiple concurrent antipsychotics in comparison to monotherapy have not been systematically investigated; existing evidence appears largely in case reports, and includes increased risk of serious drug interactions, delirium, serious behavioral changes, cardiac arrhythmias, and death (Safer, Zito, & DosReis, 2003). None of the 10 AACAP practice parameters recommended concurrent use of multiple antipsychotic medications. The AACAP Practice Parameters for the Use of Atypical Antipsychotic Medications in Children and Adolescents states, “the use of multiple AAAs [atypical antipsychotics] has not been studied rigorously and generally should be avoided.” The Texas Psychotropic Medication Utilization Parameters for Foster Children includes “two or more concomitant antipsychotic medications” as a situation that “suggests the need for additional review of a patient’s clinical status.” Constantine RJ, Boaz T, Tandon R. (2010). Antipsychotic polypharmacy in the treatment of children and adolescents in the fee-for-service component of a large state Medicaid program. Clinical therapeutics, 32, 949-959. Safer, D.J., J.M. Zito, and S. DosReis, Concomitant psychotropic medication for youths. Am J Psychiatry, 2003. 160(3): p. 438-49. AACAP Practice Parameters for the Use of Atypical Antipsychotic Medications in Children and Adolescents 2010 Texas Psychotropic Medication Utilization Parameters for Foster Children.


Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3781)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient safety process measure to reduce risk of allergic reaction to imaging contrast material.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority of making care safer by reducing harm caused in the delivery of care.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data found.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Reactions to contrast media are common, occurring in as many as 13% of patients (1) . Most reactions are mild, with severe reactions occurring in <1% of cases (1). Premedication with corticosteroids has been shown to reduce the rate of contrast reactions by as much as 35% among “high risk” patients who have had a previous reaction to contrast media (2) . 1. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. Am J Roentgenol. 1991;157:1153-1161. 2. Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM. Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast media. Am J Roentgenol. 1994;162:523-525. In a 2011 survey (1) of uroradiologists, 86% of respondents reported having a standardized premedication regimen. Additionally, the survey found significant variability in the use of premedication for specific clinical scenarios such as an urgent or emergent situation. 1. O’Malley RB, Cohan RH, Ellis JH, et al. A survey on the use of premedication prior to iodinated and gadolinium-based contrast material administration. J Am Coll Radiol. 2011;8:345-354. doi:10.1016/j.jacr.2010.09.001.


Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy for program(s): MSSP (MUC ID: X3781)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Important safety concern. Does not meet MSSP objectives.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Reactions to contrast media are common, occurring in as many as 13% of patients (1) . Most reactions are mild, with severe reactions occurring in <1% of cases (1). Premedication with corticosteroids has been shown to reduce the rate of contrast reactions by as much as 35% among “high risk” patients who have had a previous reaction to contrast media (2) . 1. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. Am J Roentgenol. 1991;157:1153-1161. 2. Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM. Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast media. Am J Roentgenol. 1994;162:523-525. In a 2011 survey (1) of uroradiologists, 86% of respondents reported having a standardized premedication regimen. Additionally, the survey found significant variability in the use of premedication for specific clinical scenarios such as an urgent or emergent situation. 1. O’Malley RB, Cohan RH, Ellis JH, et al. A survey on the use of premedication prior to iodinated and gadolinium-based contrast material administration. J Am Coll Radiol. 2011;8:345-354. doi:10.1016/j.jacr.2010.09.001.


Appendix B: Measure Specifications

Measure Index


Full Measure Specifications

MUC ID: X3766 ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE

NQF Number (if applicable):

Description: Percentage of patients age 18 years old and older with a diagnosis of cluster headache (CH) who were prescribed a guideline recommended acute medication for cluster headache within the 12-month measurement period.

Numerator statement: Patients who were prescribed a guideline recommended acute medication for cluster headache within the 12 month measurement period.

Denominator statement: All patients age 18 years old and older with a diagnosis of cluster headache.

Exclusions: Exceptions: Medical exception for not prescribing a guideline recommended acute CH medication (i.e., guideline recommended medication is medically contraindicated or ineffective for the patient; patient reports no CH attacks within the past 12 months; CH are sufficiently controlled with over the counter [OTC] medications; patient is already on an effective prescribed acute CH medication); Patient exception for not prescribing a guideline recommended acute CH medication (i.e., patient declines any prescription of an acute CH medication); System exception for not prescribing a guideline recommended acute CH medication (i.e., patient does not have insurance to cover the cost of any prescribed an acute CH medications)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3280 ADHD: Symptom Reduction in Follow-up Period

NQF Number (if applicable):

Description: Percentage of children aged 4 through 18 years, with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), who demonstrated a 25% reduction in symptoms 6-12 months from baseline as measured using the Vanderbilt ADHD Diagnostic Rating Scale, regardless of treatment prescribed.

Numerator statement: Children who demonstrated a 25% reduction in the mean response for either or both ADHD symptom screen subsegments 6-12 months from baseline assessment as measured using the Vanderbilt ADHD Diagnostic Rating Scale.

Denominator statement: Children aged 4 through 18 years, with a visit during the measurement period, and with an active diagnosis of ADHD, and who meet the diagnostic threshold of the Vanderbilt ADHD Diagnostic Rating Scale at the time of baseline assessment, and with baseline mean responses documented for the ADHD symptom screen subsegments for the Vanderbilt ADHD Diagnostic Rating Scale during the 6 months prior to the measurement period.

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR

Measure type: Patient Reported Outcome

Steward: Office of the National Coordinator for Health Information Technology/Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3732 Adult Kidney Disease: Referral to Hospice

NQF Number (if applicable):

Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care

Numerator statement: Patients who are referred to hospice care

Denominator statement: All patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis

Exclusions: Documentation of patient reason(s) for not referring to hospice care (e.g., patient declined, other patient reasons)

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Claims, Registry

Measure type: Process

Steward: Renal Physicians Association; joint copyright with American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Not Endorsed


MUC ID: X3485 Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin

NQF Number (if applicable): N/A

Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring

Numerator statement: Patients who had at least 1 INR in each 90-day interval of the measurement period during which they are on warfarin therapy

Denominator statement: Patients aged 18 and older with atrial fibrillation or atrial flutter who had been on chronic warfarin therapy for at least 180 days before the start of the measurement period. Patients should have at least one outpatient visit during the measurement period.

Exclusions: Patients on any of the following medications at any point during the measurement year: dabigatran, rivaroxaban, apixaban

HHS NQS Priority: Making Care Safer

HHS Data Source: EHR

Measure type: Process

Steward: Office of the National Coordinator for Health Information Technology

Endorsement Status: Not Endorsed


MUC ID: X3445 Alcohol Screening and Brief Intervention (ASBI) in the ER

NQF Number (if applicable):

Description: Percentage of patients aged 15 to 34 seen in the ER for injury who were screened for hazardous alcohol use AND provided a brief intervention within 7 days of the ER visit if screened positive.

Numerator statement: Numerators 1. Number of visits where patients were screened in the ER for hazardous alcohol use. A. Number of visits where patients were screened positive (also used as denominator #2) 2. Number of visits where patients were provided a brief negotiated interview (BNI) at or within seven days of the ER visit (used only with denominator #2). A. Number of visits where patients were provided a BNI at the ER visit. B. Number of visits where patients were provided a BNI not at the ER visit but within seven days of the ER visit.

Denominator statement: Number of visits for Active Clinical Plus BH patients age 15 through 34 seen in the ER for injury during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 2. Number of visits for Active Clinical Plus BH patients age 15 through 34 seen in the ER for injury and screened positive for hazardous alcohol use during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 3. Number of visits for User Population patients age 15 through 34 seen in the ER for injury during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 4. Number of visits for User Population patients age 15 through 34 seen in the ER for injury and screened positive for hazardous alcohol use during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34.

Exclusions: None

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: Indian Health Service

Endorsement Status: Not Endorsed


MUC ID: X2809 ALS Multidisciplinary Care Plan Developed or Updated

NQF Number (if applicable): N/A

Description: Percentage of patients diagnosed with ALS for whom a multi-disciplinary care plan was developed, if not done previously, and the plan was updated at least once annually.

Numerator statement: Patients for whom a multi-disciplinary care plan was developed, if not done previously, and the plan was updated at least once annually.

Denominator statement: All patients with a diagnosis of amyotrophic lateral sclerosis.

Exclusions: A system reason exclusion has been included for patients who have no insurance to cover the cost of a multidisciplinary care plan.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3817 Amblyopia Screening in Children

NQF Number (if applicable):

Description: The percentage of children who were screened for the presence of amblyopia at least once by their 6th birthday; and if necessary, were referred appropriately.

Numerator statement: Children who were screened to detect the presence of amblyopia between their 3rd and 6th birthdays, and if necessary, were referred to an eye care specialist.

Denominator statement: Children who turn 6 years of age during the measurement period and who had at least one visit during the measurement period.

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: Office of the National Coordinator for Health Information Technology/Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3811 Anesthesiology Smoking Abstinence

NQF Number (if applicable):

Description: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.

Numerator statement: Patients as defined in the Denominator who are identified as current cigarette smokers and who abstained from smoking prior to anesthesia on the day of surgery or procedure. Abstinence may be defined by either patient self-report or an exhaled carbon monoxide level of < 10 ppm. Numerator Includes: Patients 18 and older AND Are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure AND Are identified as current cigarette smokers AND Abstained from smoking prior to anesthesia on the day of surgery or procedure

Denominator statement: All patients aged 18 years and older who are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure. Denominator Includes: Patients 18 and older AND Are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure AND Are identified as current cigarette smokers

Exclusions: Non-elective emergent surgery

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Intermediate Outcome

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: X3513 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

NQF Number (if applicable): N/A

Description: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period

Numerator statement: Patients who received screening for HCV infection within the 12 month reporting period Screening for HCV infection includes: HCV antibody test or HCV RNA test

Denominator statement: All patients, regardless of age, who were seen twice for any visit or who had at least one preventive care visit within the 12 month reporting period who are active injection drug users Active injection drug users are those who have injected any drug(s) within the past 12 months

Exclusions: Exclusions: Patients with a diagnosis of chronic hepatitis C Exceptions: Documentation of medical reason(s) for not receiving annual screening for HCV (e.g., advanced disease, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not receiving annual screening for HCV (e.g., patient declined, other patient reasons)

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association

Endorsement Status: Not Endorsed


MUC ID: X3758 Appropriate age for colorectal cancer screening

NQF Number (if applicable): N/A

Description: Percentage of average-risk patients age 86 or older who underwent screening colonoscopy

Numerator statement: Patients aged 86 and older who received a routine colonoscopy screening for colorectal cancer

Denominator statement: All patients aged 50 and older who receive a routine colonoscopy screening for colorectal cancer

Exclusions: Patient under the age of 86 on the date of the procedure Patient 86 and older received a routine colonoscopy for a reason other than the following: an assessment of signs/symptoms of GI tract illness, and/or the patient is considered high risk, and/or to follow up previously diagnosed advanced lesions

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American Society for Gastrointestinal Endoscopy

Endorsement Status: Not Endorsed


MUC ID: X3759 Appropriate follow-up imaging for incidental abdominal lesions

NQF Number (if applicable):

Description: Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: - liver lesion < 1.5 cm - kidney lesion < 1.0 cm - adrenal lesion < 4.0 cm Lower performance rate is goal

Numerator statement: Final reports for abdominal imaging studies with follow-up imaging recommended

Denominator statement: All final reports for abdominal imaging studies for patients aged 18 years and older with one or more of the following noted: - liver lesion < 1.5 cm - kidney lesion < 1.0 cm - adrenal lesion < 4.0 cm

Exclusions: Exclusions: None Exceptions: Documentation of medical reason(s) that follow-up imaging is indicated (e.g., patient has a known malignancy that can metastasize, other medical reason(s)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Process

Steward: American College of Radiology

Endorsement Status: Not Endorsed


MUC ID: X3763 Appropriate follow-up imaging for incidental thyroid nodules in patients

NQF Number (if applicable): N/A

Description: Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended Lower performance rate is goal.

Numerator statement: Final reports for CT or MRI of the chest or neck or ultrasound of the neck with follow-up imaging recommended

Denominator statement: All final reports for CT or MRI studies of the chest or neck or ultrasound of the neck for patients aged 18 and older with a thyroid nodule < 1.0 cm noted

Exclusions: Exclusions: None Exceptions: Documentation of medical reason(s) for not including documentation that follow up imaging is not needed (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical reason(s))

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Process

Steward: American College of Radiology

Endorsement Status: Not Endorsed


MUC ID: X3802 Appropriate follow-up imaging for non-traumatic knee pain

NQF Number (if applicable): N/A

Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic knee pain who undergo knee magnetic resonance imaging (MRI) or magnetic resonance arthrography (MRA) who are known to have had knee radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source

Numerator statement: Imaging studies for patients known to have had knee radiographs performed within the preceding 3 months based on information from the RIS, patient-provided radiological history, or other health-care source Note: Images and/or results of prior knee radiographs should be available to the radiologist at the time of the knee MRI or MRA. If the report, but not images, from prior radiographs are available, this should be noted in the final report.

Denominator statement: All imaging studies for patients aged 18 years and older with non-traumatic knee pain who undergo knee MRI or MRA

Exclusions: None

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American College of Radiology

Endorsement Status: Not Endorsed


MUC ID: X3803 Appropriate use of imaging for non-traumatic shoulder pain

NQF Number (if applicable): N/A

Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source

Numerator statement: Imaging studies for patients known to have had shoulder radiographs performed within the preceding 3 months based on information from the RIS, patient-provided radiological history, or other health-care source Note: Images and/or results of prior shoulder radiographs should be available to radiologist at the time of the shoulder MRI, MRA, or ultrasound. If the report, but not images, from prior radiographs are available, this should be noted in the final report.

Denominator statement: All imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder MRI, MRA, or a shoulder ultrasound

Exclusions: None

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American College of Radiology

Endorsement Status: Not Endorsed


MUC ID: X3274 Assessment for Psoriatic Arthritis

NQF Number (if applicable):

Description: This measure evaluates the number of all psoriasis patients who are screened for psoriatic arthritis. Doing this helps to prevent structural damage, and maximizes quality of life (QOL).

Numerator statement: Patients who are “screened” for psoriatic arthritis. ”Screening” for psoriatic arthritis must, at a minimum, include inquiry about the presence or absence of joint symptoms including any of the following: morning stiffness, pain, redness, and/or swelling of joints. If a dermatologist wishes to perform additional optional screening measures, these may include physical examination (e.g. visualization of joints, surrounding structures (entheses) and fingers/toes for dactylitis) and/or use of a validated psoriatic arthritis screening instrument (Psoriatic Arthritis Screening and Evaluation) 2,3, ToPAS (Toronto Psoriatic Arthritis Screening) 4 or PEST (Psoriasis Epidemiology Screening Tool) 5. Numerator Instructions: To satisfy this measure, presence or absence of joint symptoms should be documented at least once during the reporting period.

Denominator statement: All patients with a diagnosis of psoriasis.

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Dermatology

Endorsement Status: Not Endorsed


MUC ID: X3783 Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders

NQF Number (if applicable):

Description: Percentage of patients diagnosed with a primary headache disorder, who are actively taking an acute headache medication and experiencing headaches >= 15 days per month for 3 months, who were assessed for medication overuse headache (MOH).

Numerator statement: Patients who were assessed for medication overuse headache (MOH).

Denominator statement: All patients diagnosed with a primary headache disorder, who are actively taking an acute headache medication and experiencing headaches >= 15 days per month for 3 months, who were assessed for medication overuse headache (MOH).

Exclusions: Exceptions: Medical Exception for not assessing the patient for MOH (i.e., patient has already had MOH ruled out within the past three months; the abortive pain medication is medically appropriate for a non-headache condition)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: E1553 Blood Pressure Screening by age 18

NQF Number (if applicable): 1553

Description: The percentage of adolescents who turn 18 years of age in the measurement year who had a blood pressure screening with results.

Numerator statement: Adolescents who had documentation in the medical record of blood pressure screening and whether results are abnormal at least once in the measurement period or the year prior.

Denominator statement: Adolescents with a visit who turned 18 years old in the measurement period.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3797 Breast Cancer Screening

NQF Number (if applicable): 2372

Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the past 27 months.

Numerator statement: Women with one or more mammograms any time on or between October 1, 27 months prior to the measurement period, and December 31 of the measurement period, not to precede the patient's 50th birthday.

Denominator statement: Women 52-74 years of age with a visit during the measurement period

Exclusions: Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Endorsed


MUC ID: X0354 Cellulitis Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Cellulitis Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Cellulitis episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a cellulitis hospital admission. The Cellulitis Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Cellulitis Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the cellulitis treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Cellulitis Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to cellulitis across a provider’s eligible cellulitis episodes during the period of performance. A cellulitis episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s cellulitis episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Adminstrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: E0032 Cervical Cancer Screening

NQF Number (if applicable): 0032

Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21-64 who had cervical cytology performed every 3 years. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.

Numerator statement: Either: 1. Women age 21-64 who had cervical cytology performed during the measurement period or in the 2 years prior to the measurement period. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or in the 4 years prior to the measurement period.[For reference, numerator for endorsed measure on QPS: The number of women who were screened for cervical cancer]

Denominator statement: Women 24-64 years of age with a visit during the measurement period[For reference, denominator for endorsed measure from QPS: Women 24-64 years of age as of the end of the measurement year.]

Exclusions: Women who had a hysterectomy with no residual cervix[For reference, exclusions for endorsed measure from QPS: Women who had a hysterectomy with no residual cervix any time during their medical history through the end of the measurement year.]

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Endorsed


MUC ID: X3775 Chronic Opioid Therapy Follow-up Evaluation

NQF Number (if applicable):

Description: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during COT documented in the medical record.

Numerator statement: Patients who had a follow-up evaluation conducted at least every three months during COT.

Denominator statement: All patients 18 and older prescribed opiates for longer than six weeks duration.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3756 Clinical Outcome post Endovascular Stroke Treatment

NQF Number (if applicable):

Description: Patients with 90 day mRs score of 0 to 2 post endovascular stroke intervention

Numerator statement: Patients with acute ischemic stroke undergoing endovascular stroke treatment who have a mRs of 0 to 2 at 90 days

Denominator statement: All patients with acute ischemic stroke undergoing endovascular stroke treatment

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Outcome

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: X3726 Clinical Response to Oral Systemic or Biologic Medications

NQF Number (if applicable):

Description: This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.

Numerator statement: Patients who have a documented physician global assessment (PGA; 6-point scale), body surface area (BSA), psoriasis area and severity index (PASI) and/or dermatology life quality index (DLQI) that meet any one of the below specified benchmarks. Numerator Instructions: To satisfy this measure, a patient must achieve any ONE of the following: a. PGA (6-point scale) < 2 (clear to mild skin disease) b. BSA < 3% (mild disease) c. PASI < 3 (no or minimal disease) d. DLQI < 5 (no effect or small effect on patient’s quality of life).9,10

Denominator statement: All patients with a diagnosis of psoriasis and treated with an oral systemic or biologic medication for psoriasis for at least 6 months.

Exclusions: Any patient for whom it is documented that he/she declines therapy change in order to achieve better disease control as measured by PGA, BSA, PASI or DLQI. - Any patient who has contraindications to or has experienced adverse effects or lack of efficacy with all other therapy options.

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Outcome

Steward: American Academy of Dermatology

Endorsement Status: Not Endorsed


MUC ID: X3283 Closing the Referral Loop - Critical Information Communicated with Request for Referral

NQF Number (if applicable): N/A

Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history

Numerator statement: Referrals for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history.

Denominator statement: Referrals sent by a referring provider to another provider during the measurement period.

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3302 Closing the Referral Loop - Specialist Report Sent to Primary Care Physician

NQF Number (if applicable): N/A

Description: Percentage of referrals received for which the receiving provider sent a consultant report back to the referring provider.

Numerator statement: Referrals received for which a consultant report is sent back to the referring provider

Denominator statement: Referrals received by a provider during the measurement period.

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3780 Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding

NQF Number (if applicable):

Description: Percentage of emergency department patients aged 18 years and older without coagulopathy or bleeding who received coagulation studies

Numerator statement: Denominator patients who received coagulation studies (PT or PTT tests)

Denominator statement: All emergency department patients aged 18 years and older presenting with chest pain, without coagulopathy or bleeding

Exclusions: Exclusions: • Diagnosis of stroke • Diagnosis of TIA • Diagnosis of DVT • Diagnosis of Acute Coronary Syndromes • Chronic liver disease • hereditary coagulopathy (286 and 286.Xcoagulation defects), hematologic diseases (289 and 289.X other blood disease • taking or being prescribed anticoagulant, anti-platelet or coagulation cascade modifying therapy, or documented concern for coagulopathy or DIC. • Pregnancy codes • Patients receiving TPA for stroke Exceptions: • traumatic injury with concern for DIC • medical illness with concern for DIC

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, EHR

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American College of Emergency Physicians

Endorsement Status: Not Endorsed


MUC ID: X3469 Cognitive Impairment Assessment Among At-Risk Older Adults

NQF Number (if applicable):

Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview.

Numerator statement: Patients with results from a standardized cognitive impairment assessment tool, or a patient or informant interview documented in the electronic health record (EHR) at least once during the measurement period.

Denominator statement: Patients age 80 or older with a visit during the measurement period.

Exclusions: Patients diagnosed with cognitive impairment or dementia before the start of the measurement period and whose diagnosis remained active throughout the measurement period.

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3735 Communication and shared decision-making with patients and families for interventional oncology procedures

NQF Number (if applicable):

Description: Percentage of patients who have undergone an interventional oncology ablation or catheter-directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was discussed with the patient and/or family member

Numerator statement: Patients who have undergone a percutaneous ablation procedure, bland embolization of a malignancy, chemoembolization or radioembolization with documentation that the intent of the procedure was discussed with the patient, and/or family member

Denominator statement: Patients who have undergone a percutaneous ablation procedure, bland embolization of a malignancy, chemoembolization or radioembolization

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR, Paper Medical Record

Measure type: Process

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: X3751 Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair

NQF Number (if applicable): N/A

Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP-Q or Baden/Walker)

Numerator statement: Number of patients that received a complete characterization of each vaginal compartment using an objective measurement of stage or grade of pelvic organ prolapse (i.e. POPQ, or Baden/Walker) as part of the assessment and evaluation of their pelvic organ prolapse. These would be identified by chart review or entry into the Registry.

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: E0055 Comprehensive Diabetes Care: Eye Exam

NQF Number (if applicable): 0055

Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who received a retinal or dilated eye exam during the measurement year or a negative retinal or dilated eye exam in the year prior to the measurement year.

Numerator statement: Members who received an eye screening for diabetic retinal disease. This includes diabetics who had the following: - A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year OR - A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. For exams performed in the year prior to the measurement year, a result must be available.

Denominator statement: Members 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Exclusions: Exclude members with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur at any time in the member’s history, but must have occurred by the end of the measurement year. Exclude members with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred by the end of the measurement year.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Endorsed


MUC ID: X3776 Consideration of Non-Pharmacologic Interventions

NQF Number (if applicable):

Description: All patients 18 and older prescribed opiates for longer than six weeks duration with whom the clinician discussed non-pharmacologic interventions (e.g. graded exercise, cognitive/behavioral therapy, activity coaching at least once during COT documented in the medical record.

Numerator statement: Patients with whom the clinician discussed non-pharmacologic interventions (e.g. graded exercise, cognitive/behavioral therapy, activity coaching) for chronic pain at least once during COT.

Denominator statement: All patients 18 and older prescribed opiates for longer than six weeks duration.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3792 Controlling High Blood Pressure

NQF Number (if applicable):

Description: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.

Numerator statement: Patients whose most recent blood pressure is adequately controlled during the measurement period.

Denominator statement: Patients 18 through 85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Intermediate Outcome

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3466 Coordinating Care - Emergency Department Referrals

NQF Number (if applicable):

Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department.

Numerator statement: Patients whose ED visit provider communicated information about the visit to their primary care provider or a specialist provider by making a telephone call or scheduling a follow up appointment with an ambulatory care provider during the visit, or transmission of electronic notification or transmission of the visit record within 24 hours of the visit.

Denominator statement: Patients (1) of any age with asthma, or (2) age 18 and over with chest pain, who had a visit to the emergency department (not resulting in an inpatient admission)

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3465 Coordinating Care - Follow-Up with Eligible Provider

NQF Number (if applicable):

Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department.

Numerator statement: Patients who were contacted by telephone by their primary care provider, relevant specialist, or their designee, or had a follow up office visit with their primary care provider, relevant specialist, or their designee within 72 hours of the visit to the emergency department.

Denominator statement: Patients (1) of any age with asthma, or (2) age 18 and over with chest pain, who had a visit to the emergency department (not resulting in an inpatient admission), and whose emergency department provider communicated information about the visit to the primary care provider or relevant specialist through: a telephone call, transmission of electronic notification, or transmission of the visit record.

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: E0067 Coronary Artery Disease (CAD): Antiplatelet Therapy

NQF Number (if applicable): 0067

Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel

Numerator statement: Patients who were prescribed aspirin or clopidogrel[For reference, numerator on endorsed measure in QPS: Patients who were prescribed aspirin or clopidogrel * within a 12 month period*Prescribed may include prescription given to the patient for aspirin or clopidogrel at one or more visits in the measurement period OR patient already taking aspirin or clopidogrel as documented in current medication list]

Denominator statement: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period

Exclusions: Documentation of medical reason(s) for not prescribing aspirin or clopidogrel (e.g., allergy, intolerant, receiving other thienopyridine therapy, bleeding coagulation disorders, receiving warfarin therapy, other medical reasons) Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (e.g., patient declined, other patient reasons) Documentation of system reason(s) for not prescribing aspirin or clopidogrel (e.g., lack of drug availability, other reasons attributable to the health care system)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Clinical Data

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Endorsed


MUC ID: E0070 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

NQF Number (if applicable): 0070

Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy There are two reporting criteria for this measure: (1) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% OR (2) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have prior myocardial infarction"[For reference, descriptin of endorsed measure from QPS: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy]

Numerator statement: REPORTING CRITERIA 1: Patients who were prescribed beta-blocker therapy REPORTING CRITERIA 2: Patients who were prescribed beta-blocker therapy

Denominator statement: REPORTING CRITERIA 1: All patients aged 18 years and older with a diagnosis of coronary artery disease or history of cardiac surgery seen within a 12 month period who also have a current or prior LVEF < 40% REPORTING CRITERIA 2: All patients aged 18 years and older with a diagnosis of coronary artery disease or history of cardiac surgery seen within a 12 month period who also have prior MI[For reference, denominator for endorsed measure on QPS: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI or a current or prior LVEF <40%]

Exclusions: Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy, intolerant, bradycardia, AV block without permanent pacemaker, arrhythmia, hypotension, asthma, other medical reasons) Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons) Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the health care system Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (e.g., patient declined, other patient reasons) Documentation of system reason(s) for not prescribing aspirin or clopidogrel (e.g., lack of drug availability, other reasons attributable to the health care system)[For reference, exclusions for endorsed measure from QPS: Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons)Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons)Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system)]

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Clinical Data

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement/American College of Cardiology/American Heart Association

Endorsement Status: Endorsed


MUC ID: X1033 Coronary Artery Disease (CAD): Symptom Management:

NQF Number (if applicable):

Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period

Numerator statement: Patients with appropriate management of anginal symptoms within a 12 month period

Denominator statement: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Clinical Data

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement/American College of Cardiology/American Heart Association

Endorsement Status: Not Endorsed


MUC ID: E0711 Depression Remission at Six Months

NQF Number (if applicable): 0711

Description: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (± 30 days) PHQ-9 score of less than five. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment.

Numerator statement: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (± 30 days) PHQ-9 score of less than five.

Denominator statement: Adults age 18 and older; no upper age limit Have the diagnosis of major depression or dysthymia defined by any of the following ICD-9 codes: 296.2x Major depressive disorder, single episode 296.3x Major depressive disorder, recurrent episode 300.4 Dysthymic disorder AND PHQ-9 Score is greater than nine. For primary care providers the diagnosis codes can be in any position (primary or secondary). For behavioral health providers the diagnosis codes need to be in the primary position. This is to more accurately define major depression and exclude patients who may have other more serious mental health diagnoses (e.g. schizophrenia, psychosis) with a secondary diagnosis of depression. Patients who do not have a six month ± 30 day PHQ-9 score obtained are included in the denominator for this measure.[For reference, denominator for endorsed measure from QPS: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine.]

Exclusions: Denominator exclusions include death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement period. Bipolar Disorder or Personality Disorder (in any position), ICD-9 Codes include: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54 , 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89, 301.0, 301.1, 301.10, 301.11, 301.12, 301.1 , 301.2, 301.20, 301.21, 301.22, 301.3, 301.4, 301.5, 301.50, 301.51, 301.59, 301.6, 301.7, 301.8, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9[For reference, exclusions for endorsed measure from QPS: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.]

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Paper Medical Record

Measure type: Patient Reported Outcome

Steward: MN Community Measurement

Endorsement Status: Endorsed


MUC ID: E0712 Depression Utilization of the PHQ-9 Tool

NQF Number (if applicable): 0712

Description: Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD-9 296.2x, 296.3x or 300.4) who have a PHQ-9 tool administered at least once during the four month measurement period.

Numerator statement: Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD-9 296.2x, 296.3x or 300.4) who have a PHQ-9 tool administered at least once during the four month measurement period.

Denominator statement: Adults age 18 and older; no upper age limit Have the diagnosis of major depression or dysthymia defined by any of the following ICD-9 codes: 296.2x Major depressive disorder, single episode 296.3x Major depressive disorder, recurrent episode 300.4 Dysthymic disorder For primary care providers the diagnosis codes can be in any position (primary or secondary). For behavioral health providers the diagnosis codes need to be in the primary position. This is to more accurately define major depression and exclude patients who may have other more serious mental health diagnoses (e.g. schizophrenia, psychosis) with a secondary diagnosis of depression.[For reference, denominator for endorsed measure from QPS: Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD-9 296.2x, 296.3x or 300.4]

Exclusions: Denominator exclusions include death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement period. Bipolar Disorder or Personality Disorder (in any position), ICD-9 Codes include: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89, 301.0, 301.1, 301.10, 301.11, 301.12, 301.1 , 301.2, 301.20, 301.21, 301.22, 301.3, 301.4, 301.5, 301.50, 301.51, 301.59, 301.6, 301.7, 301.8, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9[For reference, exclusions for endorsed measure from QPS: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.]

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR, Paper Medical Record

Measure type: Process

Steward: MN Community Measurement

Endorsement Status: Endorsed


MUC ID: E0056 Diabetes: Foot exam

NQF Number (if applicable): 0056

Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year.

Numerator statement: Patients who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year.

Denominator statement: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Exclusions: Exclude patients with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur at any time in the patient’s history, but must have occurred by the end of the measurement year. Exclude patients with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred by the end of the measurement year.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Endorsed


MUC ID: X3476 Diabetes: Hemoglobin A1c Overtreatment in the Elderly

NQF Number (if applicable):

Description: Percentage of patients 65 years of age and older with diabetes who had hemoglobin A1c < 7.0% during the measurement period.

Numerator statement: Patients whose most recent A1c level is < 7.0%

Denominator statement: Patients 65 years of age and older with diabetes who are on antihyperglycemic medications with a visit during the measurement period

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3468 Documentation of a Health Care Proxy for Patients with Cognitive Impairment

NQF Number (if applicable):

Description: The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period.

Numerator statement: Patients for whom documentation of a designated health care proxy in the medical record has been confirmed during the measurement period.

Denominator statement: All patients with (1) a positive result on a standardized assessment for cognitive impairment or (2) a diagnosis of dementia or cognitive impairment, regardless of age, prior to the start of the measurement period.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3777 Documentation of Signed Opioid Treatment Agreement

NQF Number (if applicable):

Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during COT documented in the medical record.

Numerator statement: Patients who signed an opioid treatment agreement at least once during COT.

Denominator statement: All patients 18 and older prescribed opiates for longer than six weeks duration.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3747 Door to puncture time for endovascular stroke treatment

NQF Number (if applicable):

Description: Door to puncture time less than 2 hours for patients undergoing endovascular stroke treatment

Numerator statement: Patients with acute ischemic stroke undergoing endovascular stroke treatment who have a door to puncture time of less than 2 hours

Denominator statement: All patients with acute ischemic stroke undergoing endovascular stroke treatment

Exclusions: Patients who are transferred from one institution to another with a known diagnosis of acute ischemic stroke for endovascular stroke treatment; In-patients with newly diagnosed acute ischemic stroke considered for endovascular stroke treatment

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Intermediate Outcome

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: X3774 Evaluation or Interview for Risk of Opioid Misuse

NQF Number (if applicable):

Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record.

Numerator statement: Patients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview at least once during COT.

Denominator statement: All patients 18 and older prescribed opiates for longer than six weeks duration.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3523 Extravasation of contrast following contrast-enhanced computed tomography (CT)

NQF Number (if applicable):

Description: Percentage of final reports for patients aged 18 years and older who received intravenous iodinated contrast for a computed tomography (CT) examination who had an extravasation of contrast Lower performance rate is the goal.

Numerator statement: Final reports for patients who had an extravasation of contrast Definition: Extravasation- Although most patients complain of initial swelling or tightness, and/or stinging or burning pain at the site of extravasation, some experience little or no discomfort. On physical examination, the extravasation site may be edematous, erythematous, and tender (ACR Contrast Manual, 2013)

Denominator statement: All final reports for patients aged 18 years and older who received intravenous iodinated contrast for a CT examination

Exclusions: None

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Registry, Other

Measure type: Outcome

Steward: American College of Radiology

Endorsement Status: Not Endorsed


MUC ID: X3760 Frequency of inadequate bowel preparation

NQF Number (if applicable):

Description: The percentage of outpatient examinations with “inadequate” bowel preparation that require repeat colonoscopy in one year or less

Numerator statement: Number of patients recommended for early repeat colonoscopy in one year or less due to inadequate bowel preparation

Denominator statement: Patients aged 50-75 for whom a screening or surveillance colonoscopy was performed

Exclusions: None

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American Society for Gastrointestinal Endoscopy

Endorsement Status: Not Endorsed


MUC ID: X3481 Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure

NQF Number (if applicable): N/A

Description: Percentage of patients aged 65 years and older with congestive heart failure who had a target improvement goal defined after completing an initial patient-reported functional status assessment and met the goal after completing a follow-up functional status assessment

Numerator statement: Patients who completed initial and follow-up functional status assessments using a qualifying tool, set a goal with their provider for a change in functional status score and who met the target goal by the follow-up functional status assessment

Denominator statement: Adults aged 65 years and older who had at least one outpatient encounter during the measurement year and an active diagnosis of heart failure

Exclusions: Patients with severe cognitive impairment

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Patient Reported Outcome

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3053 Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis

NQF Number (if applicable):

Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment.

Numerator statement: Patients for whom a score from one of a select list of pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment

Denominator statement: Patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis and an encounter during the measurement period who have their first encounter within the first 335 days of the measurement period

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3483 Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements

NQF Number (if applicable):

Description: Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery.

Numerator statement: Continuous Variable: Measure Observations: Average change in functional status assessment score (before and after surgery)

Denominator statement: Continuous Variable: Eligible Population: Adults, aged 19 and older during the measurement period, with a primary or total hip arthroplasty (THA) in the first 90 days of the measurement period or the last 270 days in the year prior to the measurement period and an encounter during the measurement period. Measure Population: Patients must meet the following criteria to be counted in the numerator: 1. A patient reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, HOOS) completed in the 3 months prior to or including the day of surgery 2. A patient reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, HOOS) completed during the 6-9 months after surgery 3. DO NOT have an acute fracture of hip or lower limb at the time of THA 4. DO NOT have severe cognitive impairment For a functional status assessment to be completed, the score must be documented in the EHR

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR

Measure type: Patient Reported Outcome

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3482 Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements

NQF Number (if applicable):

Description: Average change in functional status assessment score for 19 years and older with primary total knee arthroplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery.

Numerator statement: Continuous Variable: Measure Observations: Average change in functional status assessment score (before and after surgery)

Denominator statement: Continuous Variable: Eligible Population: Adults, aged 19 and older during the measurement period, with a primary total knee arthroplasty (TKA) in the first 90 days of the measurement period or the last 270 days in the year prior to the measurement period and an encounter during the measurement period Measure Population: Patients must meet the following criteria to be counted in the numerator: 1. A patient reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, KOOS) completed in the 3 months prior to or including the day of surgery 2. A patient reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, KOOS) completed during the 6-9 months after surgery 3. DO NOT have an acute fracture of hip or lower limb at the time of TKA 4. DO NOT have severe cognitive impairment For a functional status assessment to be completed, the score must be documented in the EHR

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: EHR

Measure type: Patient Reported Outcome

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X0355 Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Gastrointestinal Hemorrhage episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a gastrointestinal hemorrhage hospital admission. The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the gastrointestinal hemorrhage treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to gastrointestinal hemorrhage across a provider’s eligible gastrointestinal hemorrhage episodes during the period of performance. A gastrointestinal hemorrhage episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s gastrointestinal hemorrhage episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Adminstrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: S2521 Gout: Serum Urate Monitoring

NQF Number (if applicable): 2521

Description: Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months

Numerator statement: Patients whose serum urate level was measured within six months after initiating ULT or after changing the dose of ULT

Denominator statement: Adult patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: American College of Rheumatology

Endorsement Status: Not Endorsed


MUC ID: S2550 Gout: Urate Lowering Therapy

NQF Number (if applicable): 2550

Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)

Numerator statement: Number of patients who are prescribed urate lowering therapy.

Denominator statement: Adult patients aged 18 and older with a diagnosis of gout and a serum urate level > 6.0 mg/dL who have at least one of the following: presence of tophus/tophi or two or more gout flares (attacks) in the past year

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: American College of Rheumatology

Endorsement Status: Not Endorsed


MUC ID: X3816 Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection

NQF Number (if applicable):

Description: Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection

Numerator statement: Patients who are prescribed treatment or are referred to treatment services for HCV infection

Denominator statement: All patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result

Exclusions: Exceptions: Documentation of medical reason(s) for not being referred to treatment services for HCV infection (e.g., advanced disease, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not being referred to treatment services for HCV infection (e.g., patient declined, other patient reasons)

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association

Endorsement Status: Not Endorsed


MUC ID: X3512 Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

NQF Number (if applicable):

Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received a one-time screening for HCV infection

Numerator statement: Patients who received one-time screening for HCV infection Screening for HCV infection includes current or prior receipt of: HCV antibody test, HCV RNA test or recombinant immunoblot assay (RIBA) test

Denominator statement: All patients aged 18 years and older who were seen twice for any visit or who had at least one preventive care visit within the 12 month reporting period with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965

Exclusions: Exclusions: Patients with a diagnosis of chronic hepatitis C Exceptions: Documentation of medical reason(s) for not receiving one-time HCV antibody test (e.g., advanced disease, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not receiving one-time HCV antibody test (e.g., patient declined, other patient reasons)

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association

Endorsement Status: Not Endorsed


MUC ID: X0356 Hip Replacement/ Revision Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Hip Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Hip Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a hip replacement/revision. The Hip Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Hip Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the hip replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Hip Replacement/Revision Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the hip replacement/revision across a provider’s eligible hip replacement/revision episodes during the period of performance. A hip replacement/revision episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s hip replacement/revision episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Adminstrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: E2079 HIV medical visit frequency

NQF Number (if applicable): 2079

Description: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits

Numerator statement: Number of patients in the denominator who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between first medical visit in the prior 6-month period and the last medical visit in the subsequent 6-month period. (Measurement period is a consecutive 24-month period of time

Denominator statement: Number of patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the first 6 months of the 24-month measurement period

Exclusions: Patients who died at any time during the 24-month measurement period.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Health Resources and Services Administration (HRSA) - HIV/AIDS Bureau

Endorsement Status: Endorsed


MUC ID: X3300 HIV Screening of STI patients

NQF Number (if applicable):

Description: Percentage of patients diagnosed with an acute STI who were tested for HIV

Numerator statement: Patients with an HIV test during period extending from 30 days before STI diagnosis to 120 days after STI diagnosis

Denominator statement: Patients diagnosed with an acute STI during the one year period ending 120 days prior to the end of the measurement year. STIs include: primary and secondary syphilis, gonorrhea, chlamydia, & trichomonas.

Exclusions: Patients diagnosed with HIV/AIDS on or before the date of STI diagnosis

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Disease Control and Prevention

Endorsement Status: Not Endorsed


MUC ID: E2082 HIV Viral Load Suppression

NQF Number (if applicable): 2082

Description: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year

Numerator statement: Number of patients in the denominator with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year

Denominator statement: Number of patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the measurement year

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Outcome

Steward: Health Resources and Services Administration (HRSA) - HIV/AIDS Bureau

Endorsement Status: Endorsed


MUC ID: X3299 HIV: Ever screened for HIV

NQF Number (if applicable):

Description: Percentage of persons 15-65 ever screened for HIV

Numerator statement: Patients with documentation of an HIV test, including all persons with evidence of HIV/AIDS

Denominator statement: Patients age 15-65 with at least one outpatient visit during the one year measurement period.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Disease Control and Prevention

Endorsement Status: Not Endorsed


MUC ID: X3764 Imaging in adult ED patients with minor head injury

NQF Number (if applicable):

Description: Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) <=15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging

Numerator statement: Number of denominator patients who have a documented indication consistent with the ACEP clinical policy for mild traumatic brain injury prior to imaging Indications for Head CT in patients presenting to the ED for mild traumatic brain injury: Patients with loss of consciousness or posttraumatic amnesia AND • Headache OR; Vomiting OR; Age>60 OR; Drug/alcohol intoxication OR; Short-term memory deficits OR; Evidence of trauma above the clavicles OR; Posttraumatic seizure OR; GCS<15 OR; Focal neurological deficit OR Coagulopathy Patients without loss of consciousness or posttraumatic amnesia AND • Severe headache OR; Vomiting OR; Age>65 OR; GCS<15 OR; Physical signs of a basilar skull fracture OR; Focal neurological deficit OR; Coagulopathy OR Dangerous Mechanism Patient taking anticoagulation (warfarin, fractionated or unfractionated heparin) or has a documented coagulation disorder Dangerous mechanism of injury includes: ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs.

Denominator statement: Number of adult patients undergoing head CT for trauma who presented within 24 hours of a non-penetrating head injury with a Glasgow Coma Scale (GCS) <= 15

Exclusions: Exclusions: Number of adult patients undergoing head CT for trauma who presented within 24 hours of a non-penetrating head injury with a Glasgow Coma Scale (GCS) <= 15 Exception: Also consider potential exclusions from MTBI Pathway:

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American College of Emergency Physicians (previous steward Partners-Brigham & Women's)

Endorsement Status: Not Endorsed


MUC ID: X3778 Imaging in pediatric ED patients aged 2 through 17 years with minor head injury

NQF Number (if applicable):

Description: Percent of pediatric patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) of 14 or 15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines (PECARN) prior to imaging

Numerator statement: Number of denominator patients classified as low risk according to the PECARN clinical policy for mild traumatic brain injury prior to imaging Identification as low-risk: - No signs of altered mental status - No signs of basilar skull fracture - No history of LOC - No history of vomiting - No severe mechanism of injury - No severe headache"

Denominator statement: Number of patients aged 2 to 17 years undergoing head CT for trauma who presented within 24 hours of a non-penetrating head injury with a Glasgow Coma Scale (GCS) of 14 or 15

Exclusions: Exclusions: "• Ventricular shunt • Multisystem trauma • Coagulopathy - History of bleeding disorder such as hemophilia - History of clotting disorder - Documented concern for coagulopathy - Current treatment with an anticoagulant medication below: § Argatroban § Arixtra (Fondaparinux) § Fragmin (Dalteparin) § Heparin IV § Innohep (Tinzaparin) § Lovenox (Enoxaparin) § Pradaxa (Dabigatran) § Warfarin (Coumadin) • Thrombocytopenia or patients on any of the following medications affecting platelet function: - Aggrenox (ASA/dipyridamole) - Plavix (Clopidogrel) - Ticlid (Ticlopidine)"

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American College of Emergency Physicians

Endorsement Status: Not Endorsed


MUC ID: E1523 In-hospital mortality following elective open repair of AAAs

NQF Number (if applicable): 1523

Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers.

Numerator statement: Mortality following elective open repair of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs

Denominator statement: All elective open repairs of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs

Exclusions: Exclusion Statement: = 6 cm minor diameter - men = 5.5 cm minor diameter - women Symptomatic AAAs that required urgent/emergent (non-elective) repair

HHS NQS Priority: Making Care Safer

HHS Data Source: Registry

Measure type: Outcome

Steward: The Society for Vascular Surgery

Endorsement Status: Endorsed


MUC ID: E0555 INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555)

NQF Number (if applicable): 0555

Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin.

Numerator statement: Individuals in the denominator who have at least one INR monitoring test during each 56-day interval with warfarin.[For reference, numerator for endorsed measure from QPS: The number of individuals in the denominator who have at least one INR monitoring test during each 56-day interval with active warfarin therapy.]

Denominator statement: Individuals at least 18 years of age as of the beginning of the measurement period with warfarin therapy for at least 56 days and have at least one outpatient visit during the measurement period.[For reference, denominator for endorsed measure from QPS: Individuals at least 18 years of age as of the beginning of the measurement period with warfarin therapy for at least 56 days during the measurement period.

Exclusions: Individuals who are monitoring INR at home[For reference, additional exclusion information for endorsed measure from QPS: Optional Exclusion CriteriaIndividuals who are in long-term care (LTC) during the measurement period.]

HHS NQS Priority: Making Care Safer

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Endorsed


MUC ID: X3446 Intimate Partner (Domestic) Violence Screening

NQF Number (if applicable):

Description: Percentage of female patients aged 15-40 years old who were screened for intimate partner (domestic) violence at any time during the reporting period.

Numerator statement: GPRA: Patients screened for or diagnosed with IPV/DV during the report period. Note: This numerator does not include refusals. A. Patients with documented IPV/DV exam. B. Patients with IPV/DV related diagnosis. C. Patients provided with IPV/DV patient education or counseling. 2. Patients with documented refusal in past year of an IPV/DV exam or IPV/DV related education

Denominator statement: Female Active Clinical patients ages 13 and older. Female Active Clinical patients ages 15 through 40. (GPRA Denominator) Female User Population patients ages 13 and older.

Exclusions: None

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: Indian Health Service

Endorsement Status: Not Endorsed


MUC ID: X0351 Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Kidney/Urinary Tract Infection episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a kidney/urinary tract infection hospital admission. The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the kidney/urinary tract infection treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to kidney/urinary tract infection across a provider’s eligible kidney/urinary tract infection episodes during the period of performance. A kidney/urinary tract infection episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s kidney/urinary tract infection episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Adminstrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X0352 Knee Replacement/ Revision Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Knee Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Knee Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a knee replacement/revision. The Knee Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Knee Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the knee replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Knee Replacement/Revision Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the knee replacement/revision across a provider’s eligible Knee Replacement/Revision episodes during the period of performance. A knee replacement/revision episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s knee replacement/revision episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Administrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3791 MD Multidisciplinary Care Plan Developed or Updated

NQF Number (if applicable):

Description: All patients diagnosed with a muscular dystrophy (MD) for whom a MD multi-disciplinary care plan was developed, if not done previously, or the plan was updated at least once annually.

Numerator statement: Patients for whom a MD multi-disciplinary care plan was developed, if not done previously, or the plan was updated at least once annually.

Denominator statement: All patients diagnosed with a muscular dystrophy.

Exclusions: Exceptions: Medical reason for not developing or updating a multidisciplinary care plan (i.e., plan was updated within 12 months of the date of the encounter); • Patient reason for not developing or updating a multidisciplinary care plan (i.e., patient or family caregiver declines); • System reason for not developing or reviewing a multidisciplinary care plan (i.e., patient has no insurance to cover the cost of a seeing specialists or other clinicians in a multidisciplinary care plan, cannot travel to see specialist, multidisciplinary services unavailable)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3771 MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK

NQF Number (if applicable):

Description: Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period.

Numerator statement: Patients who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period.

Denominator statement: All patients age 12 years old and older with a diagnosis of migraine headache.

Exclusions: Exceptions: Medical exception for not prescribing a guideline recommended acute migraine medication (i.e., guideline recommended medication is medically contraindicated or ineffective for the patient; migraines are effectively controlled with OTC medications or with NSAIDs; patient is already on an effective acute migraine medication prescribed by another clinician; patient has no pain with migraine); Patient exception for not prescribing a guideline recommended acute migraine medication (i.e., patient declines a prescription for any acute migraine medication); System exception for not prescribing a guideline recommended acute migraine medication (i.e., patient does not have insurance to cover the cost of prescribed abortive migraine medication)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3796 Migraine Or Cervicogenic Headache Related Disability Functional Status

NQF Number (if applicable):

Description: Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record.

Numerator statement: Number of days during the past 3 months, as categorized by patients or their caregivers, that they are unable to perform common daily activities (e.g., school, work, household chores, social activities, Independent Activities of Daily Living (IADLS), etc.) due to migraine headache or cervicogenic headache.

Denominator statement: All patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache.

Exclusions: Exceptions: Medication exception for not administering a disability tool (i.e., patient has a cognitive or neuropsychiatric impairment that impairs his/her ability to complete the survey); Patient exception for not administering a disability tool (i.e., patient has the inability to read and/or write in order to complete the questionnaire); System exception for not administering a disability tool (i.e., patient does not have insurance to cover the cost of the quality of life assessment).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3801 Nutritional Status or Growth Trajectories Monitored

NQF Number (if applicable):

Description: All visits for patients diagnosed with muscular dystrophy (MD) where the patient’s nutritional status or growth trajectories were monitored.

Numerator statement: Patient visits where the patient’s nutritional status or growth trajectories were monitored.

Denominator statement: All visits for patients diagnosed with muscular dystrophy.

Exclusions: Exceptions: Medical reason for not monitoring for nutrition or growth trajectory problems or referring for these purposes (i.e., patient is already being following by a nutritionist or other qualified specialist for these issues); • Patient reason for not monitoring for nutrition or growth trajectory problems or referring for these purposes (i.e., patient or family caregiver declines); • System reason for not monitoring for nutrition or growth trajectory problems or referring for these purposes (i.e., patient is unable to travel)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3773 Optimal Asthma Care 2014

NQF Number (if applicable): N/A

Description: Composite (“optimal” care) measure of the percentage of pediatric and adult patients who have asthma and meet specified targets to control their asthma.

Numerator statement: The number of asthma patients who meet ALL of the following targets: A) Asthma well-controlled (take the most recent asthma control tool available during the measurement period (07/01/2013 to 06/30/2014)): · Patient has an Asthma Control Test (ACT) score of 20 or above (taken from most recent Asthma Control Test on file) – for patients 12 and older OR · Patient has a Childhood Asthma Control Test (C-ACT) score of 20 or above (taken from most recent C-ACT on file) – for patients 11 and younger OR · Patient has an Asthma Control Questionnaire (ACQ) score of 0.75 or lower (taken from most recent ACQ on file) – for patients 17 and older OR · Patient has an Asthma Therapy Assessment Questionnaire (ATAQ) score of 0 (taken from most recent ATAQ) – for children, adolescents, and adults. B) Patient not at elevated risk of exacerbation: · Patient reports values for both of the following questions (asked/documented within the measurement period): o Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months AND o Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months. · The total number of emergency department visits and hospitalizations due to asthma must be less than 2. C) Patient has been educated about his or her asthma and self-management of the condition and also has a written asthma management plan present (created or reviewed and revised within the measurement period (07/01/2013 to 06/30/2014)): Patient has a written asthma management plan in the chart with the following documented: o Plan contains information on medication doses and purposes of these medications. o Plan contains information on how to recognize and what to do during an exacerbation. o Plan contains information on the patient’s triggers.

Denominator statement: Established patient who meets each of the following criteria is included in the population: · Patient was age 5 to 50 at the start of the measurement period (date of birth was on or between 07/01/1963 to 07/01/2008). o Age 5-17 at the start of the measurement period (date of birth was on or between 07/01/1996 to 07/01/2008). o Age 18-50 at the start of the measurement period (date of birth was one or between 07/01/1963 to 06/30/1996). · Patient was seen by an eligible provider in an eligible specialty face-to-face at least two times during the last two measurement periods (07/01/2012 to 06/30/2014) with visits coded with an asthma ICD-9 code (in any position, not only primary). Use this date of service range when querying the practice management or EMR system to allow a count of the visits within the measurement period. · Patient was seen by an eligible provider in an eligible specialty face-to-face at least one time during the measurement period (07/01/2013 to 06/30/2014) for any reason. This may or may not include one of the face-to-face asthma visits. · Diagnosis of Asthma; ICD-9 diagnosis codes include: 493.00-493.12, 493.81, 493.82-493.92.

Exclusions: Patient was a permanent nursing home resident during the measurement period. · Patient was in hospice at any time during the measurement period. · Patient died prior to the end of the measurement period. · Documentation that diagnosis was coded in error. · Patients with any of the following diagnoses (see Table 2): o Cystic fibrosis (ICD-9 diagnosis codes 277.00-277.09). o COPD (ICD-9 diagnosis codes 491.20-491.22, 493.20-493.22, 496, 506.4). o Emphysema (ICD-9 diagnosis codes 492.0, 492.8, 518.1, 518.2). o Acute respiratory failure (ICD-9 diagnosis codes 518.81).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Composite [Change made from publically posted MUC list after discussion with CMS]

Steward: MN Community Measurement

Endorsement Status: Not Endorsed


MUC ID: E0076 Optimal Vascular Care

NQF Number (if applicable): 0076

Description: Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use[For reference, description of endorsed measure from QPS: Percentage of adult patients ages 18 to 75 who have ischemic vascular disease with optimally managed modifiable risk factors (blood pressure, tobacco-free status, daily aspirin use).]

Numerator statement: Patients ages 18 to 75 with ischemic vascular disease (IVD) who meet all of the following targets from the most recent visit during the measurement period: Blood Pressure less than 140/90, Tobacco-Free Status, Daily Aspirin Use (unless contraindicated). Values are collected as the most recent during the measurement period (January 1 through December 31).

Denominator statement: Patients ages 18 to 75 with ischemic vascular disease who have at least two visits for this condition over the last two measurement periods and at least one visit in the last measurement period.

Exclusions: Valid exclusions include patients who had died during the measurement period, patients in hospice during the measurement period, patients who were permanent nursing home residents during the measurement period, or patients who were coded with IVD in error.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Composite [Change made from publically posted MUC list after discussion with CMS]

Steward: MN Community Measurement

Endorsement Status: Endorsed


MUC ID: X3765 Overuse of Barbiturate Containing Medications for Primary Headache Disorders

NQF Number (if applicable):

Description: Percentage of patients age 18 years old and older with a diagnosis of primary headache who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period.

Numerator statement: Patients who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period.

Denominator statement: All patients age 18 years old and older diagnosed with a primary headache disorder.

Exclusions: Exceptions: Medical exception for prescribing a barbiturate containing medications for primary headache disorder (i.e., use as a last resort for a patient who has failed all other guideline recommended medications for headache or who have contraindications; may be considered for rescue therapy in a supervised setting for acute migraine when sedation side effects will not put the patient at risk and when the risk abuse has been addressed).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3785 Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

NQF Number (if applicable):

Description: Percentage of patients with a diagnosis of primary headache disorder with a normal neurological examination* for whom advanced brain imaging (CTA, CT, MRA or MRI) was NOT ordered. [NQF edit]

Numerator statement: Patients with a normal neurological examination for whom advanced brain imaging (CTA, CT, MRA or MRI) was NOT ordered.

Denominator statement: All patients with a diagnosis of primary headache.

Exclusions: Exceptions: Medical exceptions for ordering an advanced brain imaging study (i.e., patient has an abnormal neurological examination; patient has the coexistence of seizures, or both; recent onset of severe headache; change in the type of headache; signs of increased intracranial pressure (e.g., papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation); HIV-positive patients with a new type of headache; immunocompromised patient with unexplained headache symptoms; patient on coagulopathy/anti-coagulation or anti-platelet therapy; very young patients with unexplained headache symptoms); System exceptions for ordering an advanced brain imaging study (i.e., needed as part of a clinical trial; other clinician ordered the study).

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Efficiency [Change made from publically posted MUC list after discussion with CMS]

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3770 Overuse Of Opioid Containing Medications For Primary Headache Disorders

NQF Number (if applicable):

Description: Percentage of patients aged 12 years and older diagnosed with primary headache disorder and taking opioid containing medication who were assessed for opioid containing medication overuse within the 12-month measurement period and treated or referred for treatment if identified as overusing opioid containing medication.

Numerator statement: Patients assessed for opioid containing medication overuse within the 12-month measurement period and treated or referred for treatment if identified as overusing opioid containing medication

Denominator statement: All patients aged 12 years and older diagnosed with a primary headache disorder and taking opioid containing medication.

Exclusions: Exceptions: Medical exception for not assessing, treating, or referring patient for treatment of opioid medication overuse (i.e., patient already assessed and treated for opioid use disorder within the last year; patient has a documented failure of non-opioid options and does not have an opioid use disorder; patient has contraindications to all other medications for primary headache).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3789 Patient Counseled About Health Care Decision-Making

NQF Number (if applicable):

Description: All patients with a diagnosis of a muscular dystrophy (MD), or their caregivers who were counseled about advanced health care decision making, palliative care, or end-of-life issues at least once annually.

Numerator statement: Patients or caregivers who were counseled about advanced health care decision-making, palliative care, or end-of-life issues at least once annually.

Denominator statement: All patients with a diagnosis of a muscular dystrophy.

Exclusions: Exceptions: Medical exception for not counseling about advanced health care decision making, palliative care or end-of-life issues (i.e., patient is unable to communicate and caregiver is not available; not indicated because of early stage of disease without any comorbid complications)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3800 Patient Queried about Pain and Pain Interference with Function

NQF Number (if applicable):

Description: All visits for patients diagnosed with a muscular dystrophy (MD) where the patient was queried about pain and pain interference with function using a validated and reliable instrument.

Numerator statement: Patient visits where the patient was queried about pain and pain interference with function using a validated and reliable instrument.

Denominator statement: All visits for patients diagnosed with a muscular dystrophy.

Exclusions: Exceptions: Patient reason for not querying about pain and pain interference with function (i.e., patient declines to respond to questions)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3787 Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy

NQF Number (if applicable):

Description: All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy.

Numerator statement: Patients prescribed appropriate DMD disease modifying pharmaceutical therapy.

Denominator statement: All patients diagnosed with Duchenne muscular dystrophy (DMD).

Exclusions: Exceptions: Medication exception for not prescribing disease modifying pharmaceutical therapy (i.e., medical contraindication; patient already on corticosteroid; may not be medically appropriate depending upon functional capability, age, and existing risk factors); • Patient exception for not prescribing disease modifying pharmaceutical therapy (i.e., patient or family caregiver declines); • System exception for not prescribing disease modifying pharmaceutical therapy (i.e., patient has no insurance to cover prescription and cannot afford it)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3788 PC-02 Cesarean Section (Provider Level)

NQF Number (if applicable):

Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding).

Numerator statement: Patients with cesarean sections with ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for cesarean section

Denominator statement: Nulliparous patients delivered of a live term singleton newborn in vertex presentation ICD-9-CM Principal or Other Diagnosis Codes for pregnancy

Exclusions: ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for contraindications to vaginal delivery • Less than 8 years of age • Greater than or equal to 65 years of age • Length of Stay >120 days • Enrolled in clinical trials • Gestational Age < 37 weeks

HHS NQS Priority: Making Care Affordable

HHS Data Source: Administrative Claims, Paper Medical Record

Measure type: Outcome

Steward: American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Not Endorsed


MUC ID: X3733 Pediatric Kidney Disease: Discussion of Care Planning

NQF Number (if applicable):

Description: Percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding care planning

Numerator statement: Patients for whom there is documentation of a discussion regarding care planning Note: Although the discussion can take place with other providers, the physician overseeing the dialysis should confirm that the conversation has been undertaken either [i] directly by the nephrologist or dialysis center staff, or [ii] by another physician overseeing the patient’s care. Discussion should result in a plan to establish treatment goals based on patient's medical condition and prognosis. Discussion must endorse a family centered approach and treatment goals must be determined. The benefits and burdens of dialysis should be discussed, and the quality of the life of the individual be taken into account. Kidney transplant should be discussed if appropriate.

Denominator statement: All patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Claims, Registry

Measure type: Process

Steward: Renal Physicians Association; joint copyright with American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Not Endorsed


MUC ID: X3739 Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment

NQF Number (if applicable):

Description: Percentage of patients treated for varicose veins (CEAP C2) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that receive a disease specific patient reported outcome survey before and after treatment.

Numerator statement: Number of patients who are treated for varicose veins with saphenous ablation and receive an outcomes survey before and after treatment

Denominator statement: All patients who are treated for varicose veins with saphenous ablation

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Process [Change made from publically posted MUC list after discussion with CMS]

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: X3755 Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal

NQF Number (if applicable):

Description: Proportion of patients in whom a retrievable IVC filter is placed who, within 3 months post- placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.

Numerator statement: Number of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, either have a) the filter removed; b) documented re-assessment for the appropriateness of filter removal; or c) documentation of at least two attempts to reach the patient to arrange a clinical re-assessment for the appropriateness of filter removal

Denominator statement: All patients who have a retrievable IVC filter placed with the intent for potential removal at time of placement

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Outcome

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: X3740 Performing an intraoperative rectal examination at the time of prolapse repair

NQF Number (if applicable):

Description: Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior prolapse.

Numerator statement: Number of patients in whom an intraoperative rectal examination was performed and documented. These would be identified by chart review or entry into the Registry.

Denominator statement: Denominator = All patients undergoing apical or posterior pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis : 56800, 56810 (introital repair/ perineoplasty)

Exclusions: Patients who have undergone prior total proctectomy Patients who have exclusively anterior compartment repairs

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3752 Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury

NQF Number (if applicable):

Description: Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Numerator statement: Numerator is the number of patients in whom an intraoperative cystoscopy was performed to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Denominator statement: The number of patients undergoing hysterectomy for pelvic organ prolapse. Hysterectomy (identified by CPT codes) performed for the indication of pelvic organ prolapse (identified by supporting ICD9/ICD10 codes) The prolapse codes for ICD9 -> ICD-10 are detailed below, respectively: 618.01 -> N81.10, Cystocele, midline 618.02 -> N81.12, Cystocele, lateral 618.03 -> N81.0, Urethrocele 618.04 -> N81.6, Rectocele 618.05 -> N81.81, Perineocele 618.2 -> N81.2, Incomplete uterovaginal prolapse 618.3 -> N81.3, Complete uterovaginal prolapse 618.4 -> N81.4, Uterovaginal prolapse, unspecified 618.6 -> N81.5, Vaginal enterocele 618.7 -> N81.89, Old laceration of muscles of pelvic floor 618.81 -> N81.82, incompetence or weakening of pubocervical tissue 618.82 -> N81.83, incompetence or weakening of rectovaginal tissue 618.83 -> N81.84, pelvic muscle wasting CPT codes for hysterectomy are: 57530 Trachelectomy 58150 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo-Urethrocystopexy (e.g. Marshall-Marchetti-Krantz, Burch) 58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58260 Vaginal Hysterectomy, for Uterus 250 G or Less 58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s) 58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele 58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control 58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele 58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy 58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele 58290 Vaginal Hysterectomy, for Uterus Greater than 250 G 58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele 58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type) 58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele 58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less 58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G 58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less 58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G 58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less 58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G 58573 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)

Exclusions: None

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process [Change made from publically posted MUC list after discussion with CMS]

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: E0465 Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy

NQF Number (if applicable): 0465

Description: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery. [Note: Description is for update to NQF endorsed measure and differs from specifications provided in QPS]

Numerator statement: Patients over age 18 undergoing carotid endarterectomy who received anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists within 48 hours prior to the initiation of surgery AND are prescribed this medication at hospital discharge following surgery. [Note:Numerator is for update to NQF endorsed measure and differs from specifications provided in QPS]

Denominator statement: Patients over age 18 undergoing carotid endarterectomy.

Exclusions: Patients with known intolerance to anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists, or those on heparin or other intravenous anti-coagulants; patients with active bleeding or undergoing urgent or emergent operations or endarterectomy combined with cardiac surgery. Patients with known intolerance to anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists, or those on or other intravenous anti-coagulants; patients with active bleeding or undergoing urgent or emergent operations or endarterectomy combined with cardiac surgery. [Note: Exclusion is for update to NQF endorsed measure and differs from specifications provided in QPS]

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: The Society for Vascular Surgery

Endorsement Status: Endorsed


MUC ID: X3809 Perioperative Temperature Management

NQF Number (if applicable):

Description: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Numerator statement: Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Denominator statement: All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer

Exclusions: Exclusions: Patients undergoing: Cardiopulmonary bypass: 00561, 00562, 00563, 00566, 00567, 00580 Regional nerve block: 01958, 01960, 01967, 01991, 01992 Monitored anesthesia care: any CPT code with -QS modifier Exceptions: Documentation of one of the following medical reason(s) for not achieving at least one body temperature greater than or equal to 35.5 degrees Celsius or 95.9 degrees Fahrenheit within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Emergency cases Intentional hypothermia

HHS NQS Priority: Making Care Safer

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Process [Change made from publically posted MUC list after discussion with CMS]

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: X3761 Photodocumentation of cecal intubation

NQF Number (if applicable):

Description: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

Numerator statement: Number of patients undergoing screening or surveillance colonoscopy who have photodocumentation of landmarks of cecal intubation to establish a complete examination

Denominator statement: Patients aged 50-75 for whom a screening or surveillance colonoscopy was performed

Exclusions: Exclusions: post-surgical anatomy Exceptions: CPT Modifiers 52, 53,73, 74

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Process

Steward: American Society for Gastrointestinal Endoscopy

Endorsement Status: Not Endorsed


MUC ID: X3794 Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed

NQF Number (if applicable):

Description: All patients diagnosed with migraine headache or cervicogenic headache who had a headache management plan of care developed or reviewed at least once during the 12 month measurement period.

Numerator statement: Patients who had a headache management plan of care for migraine headache or cervicogenic headache developed or reviewed by the clinician at least once during the 12 month measurement period.

Denominator statement: All patients diagnosed with migraine headache or cervicogenic headache.

Exclusions: Exceptions: Medical exceptions for not developing or reviewing a plan of care for migraine or cervicogenic headache (i.e., patient is cognitively impaired, cannot communicate and no caregiver is available)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3784 Plan Of Care Or Referral For Possible Medication Overuse Headache

NQF Number (if applicable):

Description: Percentage of patients diagnosed with medication overuse headache (MOH) within the past 3 months or who screened positive for possible MOH (measure 6a) who had a medication overuse plan of care created or who were referred for this purpose.

Numerator statement: Patients who had a medication overuse headache plan of care created or who were referred for this purpose.

Denominator statement: All patients a diagnosis of medication overuse headache within the past three months or who screened positive for possible medication overuse headache (measure 6a).

Exclusions: Exceptions: Medical exception for not creating a medication overuse plan of care or referring the patient for this purpose (i.e., patient already has an active plan of care in place)

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3810 Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)

NQF Number (if applicable):

Description: Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.

Numerator statement: All age patients who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU) for post-procedure care for whom a checklist or protocol which includes the key transfer of care elements is utilized. • All age patients under the care of an anesthesia practitioner AND • Are transferred to another practitioner in a PACU following completion of the anesthetic care AND a transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is used. The key handoff elements that must be included in the transition of care include: 1. Identification of patient 2. Identification of responsible practitioner (PACU nurse or advanced practitioner) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issues/concerns. 6. Expectations/Plans for the early post-procedure period. 7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team

Denominator statement: All age patients who are cared for by an anesthesia practitioner and are transferred directly from the procedure room to the PACU upon completion of the anesthetic. • All age patients under the care of an anesthesia practitioner AND • Who are transferred directly to the PACU at the completion of the anesthetic. • This measure does not include transfer of care during an anesthetic or to the ICU.

Exclusions: All age patients who have been cared for by an anesthesia practitioner who are not admitted from the operating room directly to a PACU.

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Process

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: X3807 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

NQF Number (if applicable): N/A

Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member

Numerator statement: Patients who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member Definition: The key handoff elements that must be included in the transfer of care protocol or checklist include: 1. Identification of patient, key family member(s) or patient surrogate 2. Identification of responsible practitioner (primary service) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure 6. Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration 7. Opportunity for questions and acknowledgement of understanding of report from the receiving ICU team

Denominator statement: All patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an ICU directly from the anesthetizing location Any procedure including surgical, therapeutic or diagnostic

Exclusions: None

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Process

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: X3746 Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines

Numerator statement: Number of patients undergoing preoperative assessment including: 1) history asking about incontinence and its character. 2) Urinalysis documented 3) physical exam testing for stress incontinence or occult stress incontinence if patient denies symptoms of stress incontinence.

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3742 Preoperative assessment of sexual function prior to any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse

Numerator statement: Number of female patients who undergo a preoperative assessment of sexual function

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3741 Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse.

Numerator statement: Number of patients that were asked about abnormal uterine or postmenopausal bleeding, or those that had an ultrasound and/or endometrial sampling of any kind. These would be identified by chart review or entry into the Registry.

Denominator statement: The number of patients undergoing hysterectomy for pelvic organ prolapse. Hysterectomy (identified by CPT codes) performed for the indication of pelvic organ prolapse (identified by supporting ICD9/ICD10 codes) The prolapse codes for ICD9 -> ICD-10 are detailed below, respectively: 618.01 -> N81.10, Cystocele, midline 618.02 -> N81.12, Cystocele, lateral 618.03 -> N81.0, Urethrocele 618.04 -> N81.6, Rectocele 618.05 -> N81.81, Perineocele 618.2 -> N81.2, Incomplete uterovaginal prolapse 618.3 -> N81.3, Complete uterovaginal prolapse 618.4 -> N81.4, Uterovaginal prolapse, unspecified 618.6 -> N81.5, Vaginal enterocele 618.7 -> N81.89, Old laceration of muscles of pelvic floor 618.81 -> N81.82, incompetence or weakening of pubocervical tissue 618.82 -> N81.83, incompetence or weakening of rectovaginal tissue 618.83 -> N81.84, pelvic muscle wasting CPT codes for hysterectomy are: 57530 Trachelectomy 58150 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo-Urethrocystopexy (e.g. Marshall-Marchetti-Krantz, Burch) 58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58260 Vaginal Hysterectomy, for Uterus 250 G or Less 58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s) 58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele 58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control 58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele 58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy 58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele 58290 Vaginal Hysterectomy, for Uterus Greater than 250 G 58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele 58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type) 58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele 58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less 58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G 58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less 58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G 58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less 58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G 58573 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 57120 colpocleisis

Exclusions: Patients who have undergone a prior hysterectomy

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3745 Preoperative pessary for pelvic organ prolapse attempted

NQF Number (if applicable):

Description: The percentage of patients who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention

Numerator statement: Number of patients that who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention. These would be identified by chart review or entry into the Registry.

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Patients requiring surgery for a gynecologic condition who also have concurrent prolapse surgery. For example a patient with endometrial cancer who has a concurrent prolapse surgery

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3750 Preoperative pessary for pelvic organ prolapse offered

NQF Number (if applicable):

Description: The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention.

Numerator statement: Number of patients that who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention. These would be identified by chart review or entry into the Registry.

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Patients requiring surgery for a gynecologic condition who also have concurrent prolapse surgery. For example a patient with endometrial cancer who has a concurrent prolapse surgery

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3808 Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents

NQF Number (if applicable): N/A

Description: Percentage of patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to surgical start time

Numerator statement: Patients who receive aspirin 24 hours prior to surgical start time Definition: Patient reports taking aspirin OR hospital staff administered aspirin The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

Denominator statement: All patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia

Exclusions: Exclusions: None Exceptions: Documentation of medical reasons for not receiving aspirin 24 hours prior to anesthesia start time (e.g., risks of preoperative aspirin therapy are greater than the risks of withholding aspirin, other medical reasons)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Process

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: E2083 Prescription of HIV Antiretroviral Therapy

NQF Number (if applicable): 2083

Description: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year

Numerator statement: Number of patients from the denominator prescribed HIV antiretroviral therapy during the measurement year

Denominator statement: Number of patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the measurement year

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: Health Resources and Services Administration (HRSA) - HIV/AIDS Bureau

Endorsement Status: Endorsed


MUC ID: X3806 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination

NQF Number (if applicable): N/A

Description: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively

Numerator statement: Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively Definition: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to): • 5-hydroxytryptamine (5-HT3) receptor antagonists • dexamethasone • phenothiazine • phenylethylamines • butyrophenones • antihistamines • anticholinergics The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

Denominator statement: All patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for PONV Definition: Risk factors for PONV are: 1. female gender, 2. history of PONV or a history of motion sickness, 3. non-smoker, and 4. intended administration of opioids for post-operative analgesia Any procedure including surgical, therapeutic or diagnostic This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.

Exclusions: Exclusions: None Exceptions: Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (e.g., intolerance or other medical reason)

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Paper Medical Record, Registry, Other

Measure type: Process

Steward: American Society of Anesthesiologists

Endorsement Status: Not Endorsed


MUC ID: X3715 Prevention Quality Indicators #90 (PQI #90)

NQF Number (if applicable): N/A

Description: Prevention Quality Indicators (PQI) overall composite per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection.

Numerator statement: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #1 Diabetes Short-Term Complications Admission Rate • PQI #3 Diabetes Long-Term Complications Admission Rate • PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate • PQI #7 Hypertension Admission Rate • PQI #8 Heart Failure Admission Rate • PQI #10 Dehydration Admission Rate • PQI #11 Bacterial Pneumonia Admission Rate • PQI #12 Urinary Tract Infection Admission Rate • PQI #13 Angina Without Procedure Admission Rate • PQI #14 Uncontrolled Diabetes Admission Rate • PQI #15 Asthma in Younger Adults Admission Rate • PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.

Denominator statement: Population ages 18 years and older in metropolitan area† or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims

Measure type: Outcome

Steward: Agency for Healthcare Research & Quality

Endorsement Status: Not Endorsed


MUC ID: E2152 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

NQF Number (if applicable): 2152

Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user

Numerator statement: Patients who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user Definitions: Systematic screening method - For purposes of this measure, one of the following systematic methods to assess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for defining unhealthy alcohol use include: AUDIT Screening Instrument (score >= 8) AUDIT-C Screening Instrument (score >=4 for men; score >=3 for women) Single Question Screening - How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 y) or more drinks in a day? (response >=2) Brief counseling - Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking.

Denominator statement: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the 12 month measurement period[For reference, denominator for endorsed measure from QPS: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two-year measurement period]

Exclusions: Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons)

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Endorsed


MUC ID: X3772 Preventive Migraine Medication Prescribed

NQF Number (if applicable):

Description: Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is >= 4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period.

Numerator statement: Patients whose migraine frequency is >=4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period.

Denominator statement: All patients age 18 years old and older diagnosed with migraine headache.

Exclusions: Exceptions: Medical exception for not prescribing a prophylactic medication for migraine (i.e., patient migraine frequency <8 days per month or <4 attacks per month; patient is already on a prophylactic medication for migraine; patient has failed all prophylactic medications; patient has a contraindication to all migraine preventive treatments; patient adequately responding to non-pharmacologic preventive treatment); Patient exception for not prescribing a prophylactic medication for migraine (i.e., patient declines any prophylactic medication for migraine); System exception for not prescribing a prophylactic medication for migraine (i.e., patient has no insurance coverage for any prophylactic migraine medication)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3768 Primary C-Section Rate 2014

NQF Number (if applicable):

Description: A measure of the percentage of cesarean deliveries for nulliparous births.

Numerator statement: The number of live, singleton, vertex position, term (greater or equal to 37 weeks gestation) newborns who were delivered via cesarean section. When no prenatal care is provided by the medical group/clinic, the C-section delivery is not included in the numerator calculation for the C-section rate. (

Denominator statement: Patients who meet each of the following criteria is included in the measure denominator: · Female patient was nulliparous and of any age. · Patient had a single liveborn delivery. · Patient had vertex position delivery of a term (greater or equal to 37 weeks gestation) baby via a vaginal or cesarean birth. · Patient had at least one prenatal care visit with an eligible provider in an eligible specialty in the medical group prior to the onset of labor. Patient was delivered by an eligible provider in an eligible specialty who had a delivery date during the measurement period (07/01/2013 to 06/30/2014).

Exclusions: Patient had pregnancy with multiple gestations; Patient had pregnancy with a stillborn; patient had delivery with a non-vertex fetal position

HHS NQS Priority: Making Care Affordable

HHS Data Source: Administrative Claims, Paper Medical Record

Measure type: Outcome

Steward: MN Community Measurement

Endorsement Status: Not Endorsed


MUC ID: X3743 Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery

Numerator statement: Total number of patient's receiving a bladder injury at the time of surgery to repair a pelvic organ prolapse with repair during the procedure or subsequently up to 1 month post-surgery

Denominator statement: Denominator = All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Exclusions: • Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy Exceptions: Patients having concurrent surgery involving bladder neoplasia or otherwise to treat a bladder specific problem

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Paper Medical Record, Registry, Other

Measure type: Outcome

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3744 Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscous at the time of index surgery that is recognized intraoperative or within 1 month after surgery

Numerator statement: The number of patients receiving a major viscous injury with repair at the time of initial surgery or subsequently up to 1 month postoperatively

Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Registry

Measure type: Outcome

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3813 Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair

NQF Number (if applicable):

Description: Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery

Numerator statement: Number of patients receiving a ureter injury at the time of a pelvic organ prolapse procedure, with repair during the procedure or subsequently up to 1 month postoperatively

Denominator statement: Denominator = All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis

Exclusions: Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Paper Medical Record, Registry, Survey

Measure type: Outcome

Steward: American Urogynecologic Society

Endorsement Status: Not Endorsed


MUC ID: X3786 Quality Of Life Assessment For Patients With Primary Headache Disorders

NQF Number (if applicable):

Description: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.

Numerator statement: Patient whose health related quality of life was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.

Denominator statement: All patients with a diagnosis with a primary headache disorder.

Exclusions: Exceptions: Medication exception for not assessing for QoL (i.e., patient has a cognitive or neuropsychiatric impairment that impairs his/her ability to complete the HRQoL survey); Patient exception for not assessing for QoL (i.e., patient has the inability to read and/or write in order to complete the HRQoL questionnaire

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Patient Reported Outcome

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X3754 Rate of surgical conversion from lower extremity endovascular revascularization procedure

NQF Number (if applicable):

Description: In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure

Numerator statement: Number of patients undergoing major amputation or open surgical bypass within 48 hours of the index endovascular lower extremity revascularization procedure

Denominator statement: Patients undergoing endovascular lower extremity revascularization

Exclusions: Patient in denominator with planned hybrid or staged procedure

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Outcome

Steward: Society of Interventional Radiology

Endorsement Status: Not Endorsed


MUC ID: E1406 Risky Behavior Assessment or Counseling by Age 13 Years

NQF Number (if applicable): 1406

Description: The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 13 years. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity.

Numerator statement: Adolescents who had documentation of a Risky Behavior Assessment or Counseling By Age 13 Years.[For reference, numerator for endorsed measure from QPS: Children with documentation of a risk assessment or counseling for risky behaviors by 13 years of age.]

Denominator statement: Adolescents with a visit who turned 13 years of age in the measurement year.

Exclusions: None

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: E1507 Risky Behavior Assessment or Counseling by Age 18 Years

NQF Number (if applicable): 1507

Description: The percentage of children with documentation of a risk assessment or counseling for risky behaviors by 18 years of age. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity.

Numerator statement: Adolescents who had documentation of a Risky Behavior Assessment or Counseling By Age 18 Years.

Denominator statement: Adolescents with a visit who turned 18 years of age in the measurement year.

Exclusions: None

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3798 Scoliosis Evaluation Ordered

NQF Number (if applicable):

Description: All visits for patients with a diagnosis of a muscular dystrophy (MD) where the patient had a scoliosis evaluation ordered.

Numerator statement: Patients who had a scoliosis evaluation ordered.

Denominator statement: All visits for patients with a diagnosis of a muscular dystrophy.

Exclusions: Medical reason for not ordering a scoliosis evaluation (i.e., patient cannot tolerate evaluation, MD phenotype not associated with scoliosis); • Patient reason for not ordering a scoliosis evaluation (i.e., patient or family caregiver declines evaluation); • System reason for not ordering a scoliosis evaluation (i.e., patient has no insurance coverage for x-rays or referral for consultation evaluation)

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Claims, Paper Medical Record, Registry

Measure type: Process

Steward: American Academy of Neurology

Endorsement Status: Not Endorsed


MUC ID: X0353 Spine Fusion/ Refusion Clinical Episode-Based Payment Measure

NQF Number (if applicable):

Description: The Spine Fusion/Refusion Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Spine Fusion/Refusion episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a spine fusion/refusion. The Spine Fusion/Refusion Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Spine Fusion/Refusion Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the spine fusion/refusion performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.

Numerator statement: The numerator of the Spine Fusion/Refusion Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the spine fusion/refusion across a provider’s eligible spine fusion/refusion episodes during the period of performance. A spine fusion/refusion episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.

Denominator statement: A count of the provider’s spine fusion/refusion episodes during the period of performance.

Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Adminstrative Claims

Measure type: Efficiency

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3729 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

NQF Number (if applicable):

Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year.

Numerator statement: Patients who are current statin medication therapy users or who receive an order (prescription) to receive statin medication therapy

Denominator statement: Denominator 1: Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis Denominator 2: Patients aged >= 21 years at the beginning of the measurement period with any fasting or direct laboratory result of LDL-C >= 190 mg/dL Denominator 3: Patients aged 40 through 75 years at the beginning of the measurement period with Type 1 or Type 2 Diabetes with the highest fasting or direct laboratory test result of LDL-C 70 – 189 mg/dL in the measurement year or two years prior to the beginning of the measurement period"

Exclusions: Exclusions: None Exceptions: • Patients with adverse effect, allergy or intolerance to statin medication therapy • Patient who have an active diagnosis of pregnancy or breastfeeding • Patients who are receiving palliative care • Patients with active liver disease or hepatic disease or insufficiency • Patients with End Stage Renal Disease (ESRD) • Fasting or Direct LDL-C laboratory test result of < 70 mg/dL for Diabetes diagnosis who are not currently receiving statin medication therapy"

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Paper Medical Record, Registry

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X4007 Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting

NQF Number (if applicable): N/A

Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.

Numerator statement: Patients who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period

Denominator statement: All patients aged 18 years and older with a diagnosis of current alcohol dependence

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Not Endorsed


MUC ID: X4208 Substance use disorders: 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

NQF Number (if applicable):

Description: This measure is used to assess the 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.

Numerator statement: Patients who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period

Denominator statement: All patients aged 18 years and older with a diagnosis of current opioid addiction (see the related "Denominator Inclusions/Exclusions")

Exclusions: Denominator Inclusions/Exclusions Inclusions All patients aged 18 years and older with a diagnosis of current opioid addiction The term "opioid addiction" in this context corresponds to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification of opioid dependence that is characterized by a maladaptive pattern of substance use causing clinically significant impairment or distress, and manifesting by 3 (or more) of the 7 designated criteria. This classification is distinct from and not to be confused with physical dependence (i.e., tolerance and withdrawal) that is commonly experienced by patients with chronic pain who are treated with opioid analgesics. Refer to the "Rationale" field for additional information regarding this distinction. Exclusions Patients may be excluded from the denominator for medical, patient or system reasons.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: EHR

Measure type: Process

Steward: American Medical Association - Physician Consortium for Performance Improvement

Endorsement Status: Not Endorsed


MUC ID: X3475 Substance Use Screening and Intervention Composite

NQF Number (if applicable): N/A

Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

Numerator statement: Patients who received the following substance use screenings at least once within the last 24 months AND who received an intervention for all positive screening results: 1) Tobacco use component - Patients who were screened for tobacco use at least once within the last 24 months AND who received tobacco cessation intervention if identified as a tobacco user 2) Unhealthy Alcohol Use Component - Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user 3) Drug use component (nonmedical prescription drug use and illicit drug use) - Patients who were screened for nonmedical prescription drug use and illicit drug use at least once within the last 24 months using a systematic screening method AND who received brief counseling if identified as a nonmedical prescription drug user or illicit drug user

Denominator statement: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the 12 month measurement period

Exclusions: EXCEPTION (not exclusion): 1) Tobacco Component - Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reasons) 2) Alcohol Component - Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) 3) Drug Component - Documentation of medical reason(s) for not screening for nonmedical prescription drug use and illicit drug use (e.g., limited life expectancy, other medical reasons)

HHS NQS Priority: Best Practice of Healthy Living

HHS Data Source: EHR

Measure type: Process

Steward: American Society of Addiction Medicine

Endorsement Status: Not Endorsed


MUC ID: X2147 TOTAL PER CAPITA COST MEASURE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES

NQF Number (if applicable):

Description: The ratio of all actual Medicare FFS Parts A and B payments to a medical group practice for beneficiaries attributed to it over a calendar year to all expected payments to the medical group practice, multiplied by the payment for the average beneficiary in the sample.

Numerator statement: The sum of the payment-standardized actual Medicare Part A and Part B costs during the calendar year for all Medicare beneficiaries who were attributed to the medical group practice, multiplied by the actual Medicare FFS Part A and Part B payments for the average beneficiary in the sample. Note: Actual costs above the 99th percentile are set to the cost at the 99th percentile.

Denominator statement: The sum of the payment-standardized expected (based on beneficiary medical histories) Medicare Part A and Part B costs during the calendar year for all Medicare beneficiaries who were attributed to the medical group practice.

Exclusions: Exclusions: • Beneficiaries without Medicare FFS Parts A and B coverage for all 12 months of the calendar year • Beneficiaries who died in the calendar year • Beneficiaries without a prior calendar year Hierarchical Condition Category risk score (which is used to compute expected beneficiary costs) • Beneficiaries for whom non-risk-adjusted total Medicare costs were in the bottom one percent of the distribution of costs for all beneficiaries • Beneficiaries who resided outside the United States • Beneficiaries attributed to a Rural Health Clinic, Federally Qualified Health Center, Method 2 Critical Access Hospital, or Elected Teaching Amendment Hospitals.

HHS NQS Priority: Making Care Affordable

HHS Data Source: Claims

Measure type: Cost/ Resource Use

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed


MUC ID: X3769 Unnecessary Screening Colonoscopy in Older Adults

NQF Number (if applicable):

Description: Percentage of patients age 86 or older who received an unnecessary screening colonoscopy.

Numerator statement: Colonoscopy examinations performed on patients aged 86 and older for screening purposes only. Denominator Criteria (Eligible Cases): Patients aged ? 8650 years on the date of the procedure AND Patient encounter during the reporting period (CPT or HCPCS): 45378, 45380, 45381, 45383, 45384, 45385, and G0121

Denominator statement: Colonoscopy examinations performed on patients aged 86 and older for screening purposes only reported with CPT / HCPCS codes 45378, 45380, 45381, 45383, 45384, 45385, and G0121.

Exclusions: None

HHS NQS Priority: Making Care Affordable

HHS Data Source: Registry, Other

Measure type: Efficiency

Steward: American Gastroenterological Association

Endorsement Status: Not Endorsed


MUC ID: E0052 Use of Imaging Studies for Low Back Pain

NQF Number (if applicable): 0052

Description: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur).

Numerator statement: Members who received an imaging study (plain x-ray, MRI, CT scan) conducted on the index episode start date or in the 28 days following the index episode start date. A diagnosis code from Table LBP-A must be in conjunction with an imaging study code in Table LBP-D.

Denominator statement: All members aged 18 years at the beginning of the measurement year to 50 years by the end of the measurement year who had an outpatient or ED encounter with a principal diagnosis of low back pain during period starting at the beginning of the measurement year through 28 days prior to the end of the measurement year

Exclusions: Exclude patients with a low back pain diagnosis during the 180 days prior to the index episode start date. Exclude patients who have a diagnosis for which an imaging study in the presence of low back pain is clinically indicated. - Cancer: Exclude members who with a diagnosis of cancer. Look as far back as possible in the member’s history through 28 days after the index episode start date. - Recent trauma, intravenous drug abuse, neurological impairment: Exclude members who have any of these diagnoses in the 12 months prior to the index episode start date through 28 days after the index episode start date.

HHS NQS Priority: Making Care Affordable

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Endorsed


MUC ID: X3472 Use of Multiple Concurrent Antipsychotics in Children and Adolescents

NQF Number (if applicable):

Description: The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.

Numerator statement: Children and adolescents on two or more concurrent antipsychotic medications for greater than or equal to 90 days during the measurement year.

Denominator statement: Children and adolescents 1-17 years of age with a visit during the measurement year, with greater than or equal to 90 days of continuous antipsychotic medication treatment during the measurement year.

Exclusions: None

HHS NQS Priority: Making Care Safer

HHS Data Source: EHR

Measure type: Process

Steward: National Committee for Quality Assurance

Endorsement Status: Not Endorsed


MUC ID: X3781 Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy

NQF Number (if applicable): N/A

Description: Percentage of final reports for patients aged 18 years and older who had a previously documented contrast reaction who undergo any imaging examination using intravenous iodinated contrast that include documentation that the patients were pre-medicated with corticosteroids with or without H1 antihistamines

Numerator statement: Final reports for patients who were pre-medicated with corticosteroids with or without H1 antihistamines

Denominator statement: All final reports for patients aged 18 years and older with a previously documented contrast reaction who undergo any imaging examination using intravenous iodinated contrast Definition: Contrast reaction: allergic-like reaction following a prior imaging examination with intravenous iodinated contrast

Exclusions: None

HHS NQS Priority: Making Care Safer

HHS Data Source: Claims, Registry

Measure type: Process

Steward: American College of Radiology

Endorsement Status: Not Endorsed


Appendix C: Program Summaries

Program Index


Full Program Summaries

Physician Quality Reporting System (PQRS)  

Program Type: PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).

Incentive Structure: In 2012-2014, EPs could receive an incentive payment equal to a percentage (2% in 2010, gradually decreasing to 0.5% in 2014) of the EP’s estimated total allowed charges for covered Medicare Part B services under the Medicare Physician Fee Schedule. Beginning in 2015, EPs and group practices that do not satisfactorily report data on quality measures will receive a reduction (1.5% in 2015 and 2% in subsequent years) in payment.

Program Goals: The goal of the PQRS program is to encourage widespread participation by EPs to report quality information. In 2012, only 36% of EPs satisfactorily submitted quality information to PQRS.

Critical Program Objectives:

Program Update: For 2014 the PQRS program has 285 measures that may be submitted through a variety of mechanisms: claims, qualified registry, EHRs and the group reporting web interface (GPRO).  

The most recent  2012 PQRS participation report reported:


The final 2015 Physician Fee Schedule rule includes the following updates:

CMS has an ongoing Call for Measures to solicit new measures for possible inclusion in PQRS. Aside from NQF endorsement, submitters are asked to consider the following:



Physician Compare 

Program Type: Physician Compare is the federal website that reports information on physicians and other clinicians. The purpose of the web site is public reporting of information and quality measures that are meaningful to patients.

Incentive Structure: There is no incentive specific to public reporting. The information reported on the web site is derived from other programs that have various incentives.

Program Goals:

Critical Program Objectives:

Program Update: The website was launched on December 30, 2010  providing information about Medicare physicians and other health care professionals including an indication of participation in Physician Quality Reporting System (PQRS). Public reporting of performance measure results is being employed via a phased approach.  In February 2014, the first set of measure data were posted on Physician Compare. These data included a sub-set of the 2012 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) measures for the 66 group practices and 141 Accountable Care Organizations (ACOs) that successfully reported via the Web Interface. In late 2014, a similar subset of 2013 group-level measures will be reported. In 2015, the first individual eligible professional-level measures available for public reporting will be a sub-set of twenty 2014 PQRS measures and measures from the Cardiovascular Prevention measures group in support of the Million Hearts campaign.

By statute, the following types of measures are encouraged to be included for public reporting:


The final 2015 Physician Fee Schedule rule notes that beginning in 2015 all PQRS measures and all QCDR measures will be available for public reporting. Measures that are new to PQRS or a QCDR will not be publicly reported in the first year. All valid and reliable measures will be available in a downloadable file. Only those measures that are accurately understood and interpreted by consumers will be available on Physician Compare profile pages. Measures from QCDRs will be held to the same qualifications as PQRS measures, i.e., a minimum sample size of 20 and successful testing for reliability and validity.

For data collected in 2015, for publication on Physician Compare in 2016:

CMS has indicated an interest in MAP identifying those PQRS measure that are most meaningful to consumers.



Physician Feedback 

Program Type: Physician Feedback of QRURs provides comparative performance information via Quality Resource and Use Reports (QRURs) to physicians as one part of Medicare's efforts to improve the quality and efficiency of medical care.

Incentive Structure: There is no incentive specific to this reporting. The information reported to clinicians is derived from other programs that have various incentives.

Program Goals: The QRURs provide information about performance on the quality and cost measures used to calculate the Value Modifier. They allow eligible professionals to understand and improve the care they provide to Medicare beneficiaries and their performance under the Value Modifier Program.

Critical Program Objectives:

Program Update: None

Value-Based Payment Modifier 

Program Type: Value Based Payment Modifier assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. High-quality and/or low-cost groups can qualify for upward adjustments. Low- quality and/or high-cost groups and groups that fail to satisfactorily report PQRS are subject to downward adjustments

Incentive Structure: The Physician Value Based Payment Modifier is being phased in over the three years 2015-2017: CY 2015: VM will apply to physicians in groups with 100 or more eligible professionals (EPs) based on 2013 performance. CY 2016: VM will apply to physicians in groups with 10 or more EPs based on 2014 performance. CY 2017: VM will apply to physician solo practitioners and physicians in groups with 2 or more EPs based on 2015 performance. An estimated 900,000 physicians will be affected. CY 2018: VM will apply to physicians and non-physician EPs who are solo practitioners or are in groups with 2 or more EPs based on 2016 performance

Program Goals:

Critical Program Objectives:

Program Update:



Medicare and Medicaid EHR Incentive Programs 

Program Type: The Medicare and Medicaid Electronic Health Care Record (EHR) Incentive Programs provide incentive payments to eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology.

Incentive Structure: The incentive structure varies by program:


Program Goals:

Critical Program Objectives:

Program Update:



Medicare Shared Savings Program 

Program Type: MSSP is a combination pay for reporting and pay for performance program.

Incentive Structure: Option for one-sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year) or a two-sided risk model (sharing of savings and losses for all three years).

Program Goals: “Facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs.”

Critical Program Objectives:

Program Update: For 2014, the MSSP program has 33 measures that may be submitted through a CMS web interface, currently the group practice reporting (GPRO) web interface, calculated by CMS from internal and claims data, and collected through a patient and caregiver experience of care  survey.  
The 2015 Physician Fee Schedule final rule includes the following changes: