NQF
Measure Applications Partnership
Coordinating Committee
Discussion Guide
In-person meeting dates: January 26-27, 2015
National Quality Forum Conference Center
1030 15th Street NW,
9th Floor, Washington, DC 20005
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Agenda
Agenda Synopsis
Full Agenda
Day 1 |
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| 9:30 am |
Welcome, Disclosures of Interest,
Review Meeting Objectives |
|
George Isham, MAP Coordinating Committee Co-Chair
Beth McGlynn, MAP Coordinating Committee Co-Chair
Christine Cassel, President and CEO, NQF
|
| 10:00 am |
Overview of Pre-Rulemaking Approach |
|
Robert Saunders, Senior Director, NQF
|
| 10:15 am |
MAP Pre-Rulemaking Strategic
Deliverables: Cross-Cutting Issues |
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|
| 11:30 am |
Lunch |
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|
| 12:05 pm |
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|
Mark McClellan, MAP Clinician Workgroup Chair
|
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Reactors: Amir Qaseem, Bobbie
Berkowitz
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| |
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Programs considered by this workgroup include:
- Physician Quality Reporting Program
- Physician Feedback
- Physician Compare
- Value-Based Payment Modifier
- Meaningful Use for Eligible Professionals
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| |
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This section of the meeting reviews measures where the
clinician workgroup did not reach consensus on a decision.
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Measures requiring a
vote: PQRS, Physician Compare, Physician Feedback, and
Value-Based Payment Modifier |
|
Programs under consideration: Physician
Quality Reporting System (PQRS) ; Physician
Compare; Physician
Feedback; Value-Based
Payment Modifier
|
|
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Summary of workgroup deliberations:
Consensus not reached. Measures X3774, X3777,
X3776, X3775 address the important area chronic
opioid use which is a new topic area for PQRS
measures. MAP members note that although measuring
an important concept, this is little more than a
simple documentation measure. The Clinician
Workgroup did not reach consensus because some
believed the topic is important even though this
is a low value measure.
- Preliminary analysis summary: Measure of
providing alternative treatment to opioids for
pain management. Important for dual eligibles.
Conditional on submission to NQF. (Full
Preliminary Analysis)
- Preliminary analysis result: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Summary of workgroup deliberations:
Consensus not reached. MAP discussed the ongoing
controversy and changing guidelines around BP
traget values. MAP did not reach consensus noting
concerns about guidelines not being finalized and
changing measure specifications too frequently.
MAP would want the measure to be reviewed by NQF
pending final hypertension guidelines from AHA/ACC
due in 2015
- 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
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Measures requiring a
vote: Value-Based Payment Modifier |
|
Programs under consideration: Value-Based
Payment Modifier
|
|
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Summary of workgroup deliberations:
Consensus not reached. MAP did not reach consensus
on this episode based payment measure.
Gastrointestinal hemorrhage is heterogeneous and
no quality measures match up with this resource
use measure. MAP is concerned that the measure
could disincentivize appropriate use of post-acute
care. The measure doesn't reflect the variation in
inpatient costs. Developers report 30%
attributable to post-hospital care with variation
in SNF and physician services.
- 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
- 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. (Comprehensive
Measure Information)
- Public comments received: 6
- Summary of workgroup deliberations:
Consensus not reached. MAP noted that UTI is
better defined and the diagnosis more certain than
cellulitis but not as clear as hip or knee
replacement surgery for a resource use measure.
According to the measure developer much of the
variation is in the post-acute care. Matching
quality measures are needed. MAP did not reach
consensus on a recommendation for the Value-Based
Payment Modifier.
- Preliminary analysis summary: Quality
measures are needed to match this cost measure. (Full
Preliminary Analysis)
- Preliminary analysis result: Conditional
support
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| |
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This section of the meeting reviews measures that were
flagged for discussion by Coordinating Committee members.
|
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Measures Identified
for Discussion: PQRS, Physician Compare, Physician
Feedback, and Value-Based Payment Modifier |
|
Programs under consideration: Physician
Quality Reporting System (PQRS) ; Physician
Compare; Physician
Feedback; Value-Based
Payment Modifier
|
|
- 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 (Comprehensive
Measure Information)
- Public comments received: 8
- Workgroup Rationale: MAP encourages
continued development of this suite of related
measures related to care coordination including
X3283, X3465, X3466. MAP believes these measures
are necessary but not sufficient to measure
quality for care coordination. The developers
indicate that these are "building block" measures.
MAP notes that measure’s title should be revised
to reflected that a referral was initiated and not
closed. Good EHR systems are needed and measures
should assess whether systems are being used
effectively. Streamlining the transmission of
notes that PCP’s receive through EHR’s is
necessary -- there are multiple pathways within an
EHR to get a response from a specialist. The
measure applies to all EPs.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP notes that this
measure has an overly large denominator and should
consider principal diagnosis or pain/function
threshold to be captured in the denominator. MAP
prefers development as a patient-reported
functional 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. A true functional
status measure would be related to the functional
status measures for hip and knee replacement
(X3482 and X3483).
- Workgroup Recommendation: Encourage
continued development
- 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 (Comprehensive
Measure Information)
- Public comments received: 14
- Workgroup Rationale: Several Workgroup
members had significant concerns that the two
components relating to drug use are not evidence
based. A majority of the Workgroup, however,
encouraged further development of the measure
noting that prescription and illicit drug abuse is
a large and growing problem.Public comments also
indicated concerns that complying with
non-evidence-based processes will take resources
away from alcohol screening. The Clinician
Workgroup voted 67% to encourage further
development; 33% voted against.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP is delighted to
see development of true patient-reported,
functional outcome measures like this. MAP hopes
the eMeasure will be ready for use very soon and
notes that the same tool should be used to assess
before and after surgery.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: 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. Relative improvement for
severe asthmatics is not included. Minnesota uses
comparisons of like providers, i.e., pulmonologist
compared to each other, etc. Upper age limit of 50
years may not be warranted as increasing number of
older patient have asthma.
- Workgroup Recommendation: Conditional
support
- 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
(Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP suggests that
although this measure encourages use of low-cost
test before ordering an MRI, high performers may
still overuse MRIs. American College of Radiology
notes a lack of hard stop appropriateness
criteria. MAP asked - What is the pathway to true
appropriateness measures?
- Workgroup Recommendation: Encourage
continued development
- 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
(Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP suggests that
although this measure encourages use of low-cost
test before ordering an MRI, high performers may
still overuse MRIs. American College of Radiology
notes a lack of hard stop appropriateness
criteria.
- Workgroup Recommendation: Encourage
continued development
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|
Measures Identified
for Discussion: Physician Feedback Program |
|
Programs under consideration: Physician
Feedback
|
|
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP agrees that
Physician feedback of the QRURs will provide more
experience with the measure before deciding
whether it can be used for payment. Quality
measures are needed to match this cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 6
- Workgroup Rationale: MAP supported this
measures for the Physician Feedback/QRUR program
to continue to understand how the information can
be used to improve performance. Quality measures
are needed to match this cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP agrees that
Physician feedback of QRURs will provide more
information on how this measure works. Quality
measures are needed for GI hemorrhage to match
with the cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP supports this
episode-based payment measure since a hip
replacement surgery is very clearly defined.
Though surgery measures are finalized in PQRS,
additional quality measures specific to hip
replacement are needed to match this cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP supports this
episode-based payment measure since a knee
replacement surgery is very clearly defined and be
matched with 3 finalized measures for knee
replacement in PQRS. Conditional on submission to
NQF for endorsement.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP supports this
episode-based payment measure since a spine
surgery is very clearly defined. MAP is pleased to
learn that a quality measure being developed for
spine surgery to match this cost measure.
- Workgroup Recommendation: Conditional
support
|
|
Measures Identified
for Discussion:Value-Based Payment Modifier |
|
Programs under consideration: Value-Based
Payment Modifier
|
|
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP supports this
episode-based payment measure since a hip
replacement surgery is very clearly defined.
Though surgery measures are finalized in PQRS,
additional quality measures specific to hip
replacement are needed to match this cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP supports this
episode-based payment measure since a knee
replacement surgery is very clearly defined and be
matched with 3 finalized measures for knee
replacement in PQRS. Conditional on submission to
NQF for endorsement.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP supports this
episode-based payment measure since a spine
surgery is very clearly defined. MAP is pleased to
learn that a quality measure being developed for
spine surgery to match this cost measure.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP agreed that
cellulitis is heterogeneous and difficult to
define. One half of costs are inpatient including
physician services, 25% is post-hospitalization
SNF costs. The measure doesn't capture the major
variation in costs which are in the hospital.
Quality measures are needed in the topic area.
- Workgroup Recommendation: Do not
support
|
|
Measures Identified
for Discussion:Meaningful Use Program for Eligible
Professionals |
|
Programs under consideration: Medicare
and Medicaid EHR Incentive Programs for Eligible
Professionals
|
|
- 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 (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP encourages
continued development of this suite of related
measures related to care coordination including
X3283, X3465, X3466. MAP believes these measures
are necessary but not sufficient to measure
quality for care coordination. The developers
indicate that these are "building block" measures.
MAP notes that measure’s title should be revised
to reflected that a referral was initiated and not
closed. Good EHR systems are needed and measures
should assess whether systems are being used
effectively. Streamlining the transmission of
notes that PCP’s receive through EHR’s is
necessary -- there are multiple pathways within an
EHR to get a response from a specialist. The
measure applies to all EPs.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP notes that this
measure has an overly large denominator and should
consider principal diagnosis or pain/function
threshold to be captured in the denominator. MAP
prefers development as a patient-reported
functional 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. A true functional
status measure would be related to the functional
status measures for hip and knee replacement
(X3482 and X3483).
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 5
- Workgroup Rationale: MAP is delighted to
see development of true patient-reported,
functional outcome measures like this. MAP hopes
the eMeasure will be ready for use very soon and
notes that the same tool should be used to assess
before and after surgery.
- Workgroup Recommendation: Encourage
continued development
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| |
|
|
This section of the meeting finalizes the clinician
workgroup recommendations for:
|
| 1:55 pm |
Opportunity for Public Comment |
|
|
| 2:10 pm |
Break |
|
|
| 2:25 pm |
|
|
Carol Raphael, MAP PAC/LTC Workgroup Chair
|
|
Reactors: Cheryl Phillips, Alison
Shippy
|
| |
|
|
Programs considered by this workgroup include:
- Inpatient Rehabilitation Facilities Quality
Reporting Program
- Long-Term Care Hospitals Quality Reporting Program
- End-Stage Renal Disease Quality Incentive Program
- Skilled Nursing Facilities Value-Based Purchasing
- Home Health Quality Reporting Program
- Hospice Quality Reporting Program
|
|
|
|
This section of the meeting reviews measures where the
PAC/LTC workgroup did not reach consensus on a decision. |
|
Programs under consideration: End-Stage
Renal Disease Quality Incentive Program
|
|
- Documentation of Current Medications in the
Medical Record (MUC ID: E0419)
- Description: Percentage of specified
visits for patients aged 18 years and older for
which the eligible professional attests to
documenting a list of current medications to the
best of his/her knowledge and ability. This list
must include ALL prescriptions, over-the-counters,
herbals, and vitamin/mineral/dietary (nutritional)
supplements AND must contain the medications’
name, dosage, frequency and route of
administration (Comprehensive
Measure Information)
- Public comments received: 4
- Summary of workgroup deliberations:
Consensus not reached. Split between conditional
support and do not support. MAP considered both
the outcome and reporting version of this measure,
noting the reporting version serves as an
important first step towards implementing the
outcome measure. MAP recognized the importance of
medication documentation but raised concerns about
the feasibility of this measure. MAP members noted
that most prescriptions are written outside of the
dialysis facility and it can be challenging for
providers to determine what medications a patient
is taking. Some members also expressed concerns
that this is a check box metric that will not
improve medication reconcilliation. However, other
members noted that this measure addresses a
critical program objective that the measure set
should expand beyond dialysis procedures to
include cross-cutting aspects of care, including
medication reconciliation. It also addresses the
NQS priority of safety and is included in the MAP
duals family.
- Preliminary analysis summary: Support is
conditional on the measure being tested at the
levels appropriate for ESRD facilities.It
addresses a critical program objective that the
measure set should expand beyond dialysis
procedures to include non clinical aspects of
care, including medication reconciliation. It also
addresses the NQS priority of safety and is
included in the MAP duals family. It promotes
alignment across federal programs as it is used in
clinician programs (e.g. PQRS, MU) and was
recently finalized for use in MSSP. (Full
Preliminary Analysis)
- Preliminary analysis result: Conditional
support
- Cultural Competency Implementation Measure (MUC
ID: E1919)
- Description: The Cultural Competence
Implementation Measure is an organizational survey
designed to assist healthcare organizations in
identifying the degree to which they are providing
culturally competent care and addressing the needs
of diverse populations, as well as their adherence
to 12 of the 45 NQF-endorsed® cultural competency
practices prioritized for the survey. The target
audience for this survey includes healthcare
organizations across a range of health care
settings, including hospitals, health plans,
community clinics, and dialysis organizations.
Information from the survey can be used for
quality improvement, provide information that can
help health care organizations establish
benchmarks and assess how they compare in relation
to peer organizations, and for public reporting. (Comprehensive
Measure Information)
- Public comments received: 5
- Summary of workgroup deliberations:
Consensus not reached. Split between conditional
support and do not support. MAP considered both
the outcome and reporting version of this measure,
noting the reporting version serves as an
important first step towards implementing the
outcome measure. MAP recognized the importance of
cultural competency but raised concerns that this
measure has limited testing in the dialysis
facility setting. While some members raised
concerns about the burden of this measure, CMS
clarified that data would be collected through a
survey administered once per year per site. Other
MAP members noted that this measure addresses a
critical program objective of expanding the
measure set to include cross-cutting aspects of
care such as patient engagement. Culturally
competent care improves patient engagement. It
addresses the NQS priority of person and family
engagement and is NQF endorsed. While this measure
is not publicly reported, it could be used as a
means of assessing whether standards for providing
culturally competent care are being met and
specifically, the degree to which healthcare
organizations are adhering to the NQF-endorsed
preferred practices for providing culturally
competent care.
- Preliminary analysis summary: The measure
addresses a critical program objective of
expanding the measure set to include nonclinical
aspects of care such as patient engagement.
Culturally competent care improves patient
engagement. It addresses the NQS priority of
person and family engagement and is NQF endorsed.
While this measure is not publicly reported, it
could be used as a means of assessing whether
standards for providing culturally competent care
are being met and specifically, the degree to
which healthcare organizations are adhering to the
NQF-endorsed preferred practices for providing
culturally competent care. (Full
Preliminary Analysis)
- Preliminary analysis result: Support
- Cultural Competency Reporting Measure (MUC
ID: X3716)
- Description: This reporting measure is
designed to collect data needed to score NQF #1919
in the ESRD QIP. (Comprehensive
Measure Information)
- Public comments received: 5
- Summary of workgroup deliberations:
Consensus not reached. Split between conditional
support and do not support. MAP considered both
the outcome and reporting version of this measure,
noting the reporting version serves as an
important first step towards implementing the
outcome measure. MAP recognized the importance of
cultural competency but raised concerns that this
measure has limited testing in the dialysis
facility setting. While some members raised
concerns about the burden of this measure, CMS
clarified that data would be collected through a
survey administered once per year per site. Other
MAP members noted that this measure addresses a
critical program objective of expanding the
measure set to include cross-cutting aspects of
care such as patient engagement. Culturally
competent care improves patient engagement. This
measure addresses the NQS priority of person and
family engagement.
- Preliminary analysis summary: This
measure meets a critical program objective
previously identified by MAP that the measure set
should expand beyond dialysis procedures to
include nonclinical aspects of care such as
patient engagement; culturally competent care
improves patient engagement.This measure would
serve as an important first step in assessing
cultural competency. However, MAP would encourage
the rapid implementation of NQF #1919. (Full
Preliminary Analysis)
- Preliminary analysis result: Conditional
support
- Medications Documentation Reporting (MUC ID:
X3721)
- Description: This reporting measure is
designed to collect data needed to score NQF #0419
in the ESRD QIP. (Comprehensive
Measure Information)
- Public comments received: 7
- Summary of workgroup deliberations:
Consensus not reached. Split between conditional
support and do not support. MAP considered both
the outcome and reporting version of this measure,
noting the reporting version serves as an
important first step towards implementing the
outcome measure. MAP recognized the importance of
medication documentation but raised concerns about
the feasibility of this measure. MAP members noted
that most prescriptions are written outside of the
dialysis facility and it can be challenging for
providers to determine what medications a patient
is taking. Some members also expressed concerns
that this is a check box metric that will not
improve medication reconciliation. However, other
members noted that this measure addresses a
critical program objective that the measure set
should expand beyond dialysis procedures to
include cross-cutting aspects of care, including
medication reconciliation. It also addresses the
NQS priority of safety and is included in the MAP
duals family.
- Preliminary analysis summary: Conditional
support pending NQF endorsement. Measure addresses
a critical program objective to expand the measure
set beyond dialysis procedures to include non
clinical aspects of care, including medication
reconciliation. Addresses the gap area and NQS
priority of safety(inappropriate medication use)
and effective communication and coordination
ofcare.This reporting measure is designed to
collect data needed to score NQF #0419 in the ESRD
QIP. (Full
Preliminary Analysis)
- Preliminary analysis result: Conditional
support
|
| |
|
|
This section of the meeting finalizes the PAC/LTC
workgroup recommendations for:
|
| 3:50 pm |
Opportunity for Public Comment |
|
|
| 4:00 pm |
Adjourn for the Day |
|
|
Day 2 |
|
|
|
| 9:30 am |
Day 1 Recap |
|
|
| 9:35 am |
|
|
Frank Opelka, MAP Hospital Workgroup Co-Chair
Ron
Walters, MAP Hospital Workgroup Co-Chair
|
|
Reactors: Elizabeth Mitchell, Bill
Kramer
|
| |
|
|
Programs considered by this workgroup include:
- Inpatient Quality Reporting Program
- Hospital Value-Based Purchasing Program
- Hospital Readmission Reduction Program
- Hospital-Acquired Condition Reduction Program
- Hospital Outpatient Quality Reporting Program
- Ambulatory Surgical Centers Quality Reporting
Program
- Medicare and Medicaid EHR Incentive Program for
Hospitals and Critical Access Hospitals
- PPS-Exempt Cancer Hospital Quality Reporting Program
- Inpatient Psychiatric Facilities Quality Reporting
Program
|
|
|
|
This section of the meeting reviews measures where the
hospital workgroup did not reach consensus on a decision. |
|
Programs under consideration: Hospital
Outpatient Quality Reporting Program
|
|
- Advance Care Plan (MUC ID: E0326)
- Description: Percentage of patients aged
65 years and older who have an advance care plan
or surrogate decision maker documented in the
medical record or documentation in the medical
record that an advance care plan was discussed but
the patient did not wish or was not able to name a
surrogate decision maker or provide an advance
care plan. [Description differs from posted MUC
list based on NQF staff analysis] (Comprehensive
Measure Information)
- Public comments received: 6
- Summary of workgroup deliberations:
Consensus not reached. No Decision. Vote Result:
39% Support; 17% Conditional Support; 43% Do Not
Support. This measure was extensively discussed by
the MAP Hospital workgroup members and ultimately
they were not able to reach consensus on the
disposition of this measure. The workgroup agreed
to send this measure to the MAP Coordinating
Committee for further discussion and final
decision. The group did take a straw poll vote to
provide the Coordinating Committee with a
preliminary assessment of the workgroup. The
members of the workgroup broadly agreed on the
importance of an advanced care plan. Some members
urged that every opportunity to discuss advanced
directives needs to be taken and that all
providers have a responsibility to have these
conversations, including outpatient facilities.
Others argued that these conversations require an
ongoing provider and patient relationship and it
is under that context where these conversations
are most appropriate. Further, others argued that
the measure as specified is a simple check the box
measure and does not have the potential to truly
improve patient care.
- Preliminary analysis summary: This
measure addresses an important aspect of patient
engagement, promotes alignment across programs,
and is NQF-endorsed. (Full
Preliminary Analysis)
- Preliminary analysis result:
Support
|
| |
|
|
This section of the meeting reviews measures that were
flagged for discussion by Coordinating Committee members.
|
|
Measures for
Discussion: Inpatient Quality Reporting Program |
|
Programs under consideration: Inpatient
Quality Reporting Program
|
|
- Adverse Drug Events: - Inappropriate Renal Dosing
of Anticoagulants (MUC ID: X3323)
- Description: Percentage of patient-drug
days with administration of anticoagulants
requiring renal dosing with at least one error in
renal dosing (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP members agreed
that this measure addresses a critical gap in
adverse drug events. Anticoagulants are a high
risk class of drugs that should be administered
carefully to renal patients, for whom the effects
of many drugs differ from non-renal patients. The
MAP encouraged further development of this measure
at the facility level, testing, and submission to
NQF for endorsement.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP conditionally
supported this measure pending NQF review and
endorsement. Members noted that this measure
addresses the cost of care an important condition.
Other members expressed caution on the use of this
measure noting that cellulitis is a highly
variable condition that may be challenging to
measure using a episode-based framework. MAP
encouraged the relevant NQF Standing Committee to
consider this issue in its review of this measures
for endorsement.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 5
- Workgroup Rationale: MAP conditionally
supported this measure pending NQF review and
endorsement. Members noted that this measure
addresses the cost of care for common conditions.
Kidney/UTIs are mainly treated on an outpatient
basis but the cost of care can be high if
hospitalization and follow-up is required. Other
members expressed caution that the most efficient
providers may reduce overall hospitalizations thus
those hospitalizations that remain are a biased
sample for measuring performance across providers.
The relevant NQF Standing Committee should
consider these issues in its review of these
measures for endorsement.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP conditionally
supported this measure pending NQF review and
endorsement. Members noted that this measure
addresses the cost of care for GI bleeding.
Several members expressed caution that the most
efficient providers may reduce overall
hospitalizations thus those inpatient
hospitalizations that remain are a biased sample
for measuring performance across providers. The
relevant NQF Standing Committee should consider
these issues in its review of these measures for
endorsement.?
- Workgroup Recommendation: Conditional
support
- Hospital 30-day, all-cause, risk-standardized
mortality rate (RSMR) following pneumonia
hospitalization (MUC ID: E0468)
- Description: The measure estimates a
hospital 30-day risk-standardized mortality rate
(RSMR), defined as death for any cause within 30
days after the date of admission of the index
admission, for patients 18 and older discharged
from the hospital with a principal diagnosis of
pneumonia. CMS annually reports the measure for
patients who are 65 years or older and are either
enrolled in fee-for-service (FFS) Medicare and
hospitalized in non-federal hospitals or are
hospitalized in Veterans Health Administration
(VA) facilities. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: Conditional support
pending NQF review of the updates to this measure
and continued endorsement. MAP conditionally
supported this measure pending NQF review of the
updates to this measure and continued endorsement.
MAP reviewed a revised version of this measure
that would expand the cohort of patients included
in the measure to include patients with a primary
diagnoses of aspiration pneumonia and sepsis. The
MAP noted that pneumonia mortality remains an
important area of hospital quality and this
expanded measure could potentially reduce coding
biases. This high-impact fully specified, tested
and endorsed outcome measure is already in use in
several public and private programs including IQR.
- Workgroup Recommendation: Conditional
support
- Participation in a Patient Safety Culture Survey
(MUC ID: X3689)
- Description: Participation in a patient
safety culture survey involves a) What is the name
of the survey? b) How frequently is the survey
administered? c) Which staff positions complete
the survey? d) Are survey results reported to a
centralized location? e) What is the survey
response rate? (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP was supportive
of including this structural measure in the IQR
program. Workgroup members noted that
participation in a patient safety culture survey
is an important element to building a system of
quality improvement within health care facilities.
While some MAP members noted that ideally results
of a patient safety culture survey would be made
publiclly available, the group agreed that there
are limitations to reporting the results of the
tools currently used such as the use of two
different surveys that can not be
cross-referenced.
- Workgroup Recommendation: Support
- Hospital 30-day, all-cause, risk-standardized
readmission rate (RSRR) following pneumonia
hospitalization (MUC ID: E0506)
- Description: The measure estimates a
hospital-level risk-standardized readmission rate
(RSRR) for patients discharged from the hospital
with a principal diagnosis of pneumonia. The
outcome is defined as unplanned readmission for
any cause within 30 days of the discharge date for
the index admission. A specified set of planned
readmissions do not count as readmissions. The
target population is patients 18 and over. CMS
annually reports the measure for patients who are
65 years or older and are either enrolled in
fee-for-service (FFS) Medicare and hospitalized in
non-federal hospitals or are hospitalized in
Veterans Health Administration (VA) facilities. (Comprehensive
Measure Information)
- Public comments received: 6
- Workgroup Rationale: Conditional support
pending NQF review of the expanded measure and
consideration for SDS adjustment in the NQF trial
period. MAP conditionally supported a revised
version of the measure that would expand the
cohort of patients included in the measure to
include patients with a primary diagnoses of
aspiration pneumonia and sepsis for use in the IQR
program. While MAP members agreed that this is a
high-impact outcome measure, part of the MAP
Safety Family of Measures, and in use in several
public and private programs, they did express
caution over the implementation of this updated
version. MAP recommended that the expanded measure
be submitted for NQF endorsmenet and that CMS
implement the new measure in a way that minimizes
confusion.The MAP noted support of this measure on
the condition that this measure is considered for
SDS adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual
relationship between SDS factors and pneumonia
readmissions, and endorsed with appropriate
consideration of SDS factors if determined by NQF
standing committees.
- Workgroup Recommendation: Conditional
support
- 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. (Comprehensive
Measure Information)
- Public comments received: 6
- Workgroup Rationale: MAP conditionally
supported this measure pending NQF review and
endorsement. Some members raised concerns that
patients with cancer should be excluded from this
measure. The relevant NQF Standing Committee
should consider these issues in its review of
these measures for endorsement.?
- Workgroup Recommendation: Conditional
support
- National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI)
Outcome (MUC ID: S0138)
- Description: CAUTI can be minimized by a
collection of prevention efforts. These include
reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters
to the patient´s leg to avoid bladder and urethral
trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic
technique for urinary catheter insertion. These
efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized
standard for HAI monitoring, leads to improved
patient outcomes and provides a mechanism for
identifying improvements and quality efforts. (Comprehensive
Measure Information)
- Public comments received: 6
- Workgroup Rationale: MAP supported the
implementation of an updated version of this
measure currently in the IQR Program. This update
was recently reviewed and recommended by the NQF
Safety Standing Committee. Implementing this
updated measure would extend the measure to
hospital settings outside the ICU and add another
risk adjustment methodology. The two risk
adjustment methodologies are: Standardized
Infection Ratio (SIR) uses a stratification
approach to compare CAUTIs incidence rates. For
example, the stratification can be by the
hospital’s patient care location as the predicted
number of CAUTIs in a medical ICU may be different
then a general medical/surgical unit. Adjusted
Ranking Metric (ARM) uses a more complex Bayesian
estimation technique to account for the small
sample sizes that may be present in the strata
described in the SIR above. To adjust for this
potentially low precision and/or reliability due
to sample size, a statistical adjustment is made
to the numerator. The MAP was supportive of using
this measure in the IQR program to gain some
experience in the measure for CMS and providers.
Expanding the measure from the ICU to other
locations in the hospital significantly adjusts
the measure and experience is needed. The MAP also
acknowledged concerns raised by providers
specializing in the treatment of spinal cord
injuries and encouraged further consideration on
the trade-offs of including these patients in this
measure population. Finally, several MAP members
noted that the ARM calculation is very difficult
to replicate without coefficients from CDC and
urged CDC and CMS to make all elements of the
calculation transparent.
- Workgroup Recommendation: Support
- National Healthcare Safety Network (NHSN) Central
line-associated Bloodstream Infection (CLABSI)
Outcome (MUC ID: S0139)
- Description: CLABSI can be minimized
through proper management of the central line.
Efforts to improve central line insertion and
maintenance practices, with early discontinuance
of lines are recommended. These efforts result in
decreased morbidity and mortality and reduced
healthcare costs. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP was supportive
of including this structural measure in the IQR
program. Workgroup members noted that
participation in a patient safety culture survey
is an important element to building a system of
quality improvement within health care facilities.
While some MAP members noted that ideally results
of a patient safety culture survey would be made
publiclly available, the group agreed that there
are limitations to reporting the results of the
tools currently used such as the use of two
different surveys that can not be
cross-referenced.
- Workgroup Recommendation: Support
- Timely Evaluation of High-Risk Individuals in the
Emergency Department (MUC ID: X1234)
- Description: Median time from emergency
department (ED) arrival to provider evaluation for
individuals triaged at the two highest levels
based on a five-level triage system (e.g., triaged
as “immediate” or “emergent”). (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP has previously
stressed the importance of ED throughput measures
as important markers of efficiency and safety
which can dramatically impact patient
experience.This measure in particular would
address severely ill patients being admitted to
the ED. The MAP encouraged continued development
of this e-measure it may have the potential to
capture important clinical data.
- Workgroup Recommendation: Encourage
continued development
|
|
Measures for
Discussion: Outpatient Quality Reporting Program |
|
Programs under consideration: Hospital
Outpatient Quality Reporting Program
|
|
- Administrative Communication (MUC ID: E0291)
- Description: Percentage of patients
transferred to another healthcare facility whose
medical record documentation indicated that
administrative information was communicated to the
receiving facility within prior to departure (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Vital Signs (MUC ID: E0292)
- Description: Percentage of patients
transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that the
entire vital signs record was communicated to the
receiving FACILITY within 60 minutes of departure
(Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Medication Information (MUC ID: E0293)
- Description: Percentage of patients
transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that
medication information was communicated to the
receiving FACILITY within 60 minutes of departure
(Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Patient Information (MUC ID: E0294)
- Description: Percentage of patients
transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that
patient information was communicated to the
receiving FACILITY within 60 minutes of departure
(Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Physician Information (MUC ID: E0295)
- Description: Percentage of patients
transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that
physician information was communicated to the
receiving FACILITY within 60 minutes of departure
(Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Nursing Information (MUC ID: E0296)
- Description: Percentage of patients
transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that
nursing information was communicated to the
receiving FACILITY within 60 minutes of departure
(Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
- Procedures and Tests (MUC ID: E0297)
- Description: Percentage of patients
transferred to another healthcare facility whose
medical record documentation indicated that
procedure and test information was communicated to
the receiving FACILITY within 60 minutes of
departure (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: The MAP agreed to
support this measure conditional on condensing the
components into one measure and endorsement as one
comprehensive measure. This measure would help to
address a previously identified gap around
improving care coordination and would help ensure
vital information is transferred between sites of
care. These measures are the Emergency Department
Transfer Communication Measure set which consists
of seven components that focus on communication
between facilities around the transfer of
patients. The measure set assists in filling the
workgroup identified priority gap of enhancing
care coordination efforts. After the Hospital
Workgroup meeting, the measure developer clarified
that the measure has been updated to include all
the components in a comprehensive measure. The
Coordinating Committee will be asked to consider
supporting this measure without conditions.
- Workgroup Recommendation: Conditional
support
|
|
Measures for
Discussion: Hospital Value-Based Purchasing Program |
|
Programs under consideration: Hospital
Value-Based Purchasing Program
|
|
- National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI)
Outcome (MUC ID: S0138)
- Description: CAUTI can be minimized by a
collection of prevention efforts. These include
reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters
to the patient´s leg to avoid bladder and urethral
trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic
technique for urinary catheter insertion. These
efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized
standard for HAI monitoring, leads to improved
patient outcomes and provides a mechanism for
identifying improvements and quality efforts. (Comprehensive
Measure Information)
- Public comments received: 7
- Workgroup Rationale: MAP conditionally
supported the implementation of an updated version
of a measure currently in the VBP program but
noted caution that the measure should be
publically reported prior to use in a payment or
penalty program to allow for some experience in
the measure for CMS and providers. This update was
recently reviewed and recommended by the NQF
Safety Standing Committee. Implementing this
updated measure would extend the measure to
hospital settings outside the ICU and add another
risk adjustment methodology. The two risk
adjustment methodologies are: Standardized
Infection Ratio (SIR) uses a stratification
approach to compare CAUTIs incidence rates. For
example, the stratification can be by the
hospital’s patient care location as the predicted
number of CAUTIs in a medical ICU may be different
then a general medical/surgical unit. Adjusted
Ranking Metric (ARM) uses a more complex Bayesian
estimation technique to account for the small
sample sizes that may be present in the strata
described in the SIR above. To adjust for this
potentially low precision and/or reliability due
to sample size, a statistical adjustment is made
to the numerator. Expanding the measure from the
ICU to other locations in the hospital
significantly adjusts the measure and experience
is needed. The MAP also acknowledged concerns
raised by providers specializing in the treatment
of spinal cord injuries and encouraged further
consideration on the trade-offs of including these
patients in this measure population. Finally,
several MAP members noted that the ARM calculation
is very difficult to replicate without
coefficients from CDC and urged CDC and CMS to
make all elements of the calculation transparent.
MAP also cautioned that CMS should take steps to
minimize confusion when implementing updates to
measures currently being used.
- Workgroup Recommendation: Conditional
support
- National Healthcare Safety Network (NHSN) Central
line-associated Bloodstream Infection (CLABSI)
Outcome (MUC ID: S0139)
- Description: CLABSI can be minimized
through proper management of the central line.
Efforts to improve central line insertion and
maintenance practices, with early discontinuance
of lines are recommended. These efforts result in
decreased morbidity and mortality and reduced
healthcare costs. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP conditionally
supported the implementation of an updated version
of this measure currently in the VBP Program but
they noted caution that the measure should be
publically reported prior to use in a payment or
penalty program to allow for some experience in
the measure for CMS and providers. This update was
recently reviewed and recommended by the NQF
Safety Standing Committee. Implementing this
updated measure would extend the measure to
hospital settings outside the ICU and add another
risk adjustment methodology. The two risk
adjustment methodologies are: Standardized
Infection Ratio (SIR) uses a stratification
approach to compare CLABSI incidence rates. For
example, the stratification can be by the
hospital’s patient care location as the predicted
number of CLABSIs in a medical ICU may be
different then a NICU. Adjusted Ranking Metric
(ARM) uses a more complex Bayesian estimation
technique to account for the small sample sizes
that may be present in the strata described in the
SIR above. To adjust for this potentially low
precision and/or reliability due to sample size, a
statistical adjustment is made to the numerator.
MAP noted that expanding the measure from the ICU
to other locations in the hospital significantly
adjusts the measure and measure use experience is
needed. MAP also cautioned that CMS should take
steps to minimize confusion when implementing
updates to measures currently being used.
- Workgroup Recommendation: Conditional
support
- Hospital 30-day, all-cause, risk-standardized
mortality rate (RSMR) following pneumonia
hospitalization (MUC ID: E0468)
- Description: The measure estimates a
hospital 30-day risk-standardized mortality rate
(RSMR), defined as death for any cause within 30
days after the date of admission of the index
admission, for patients 18 and older discharged
from the hospital with a principal diagnosis of
pneumonia. CMS annually reports the measure for
patients who are 65 years or older and are either
enrolled in fee-for-service (FFS) Medicare and
hospitalized in non-federal hospitals or are
hospitalized in Veterans Health Administration
(VA) facilities. (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP conditionally
supported this measure pending NQF review of the
updates to this measure and continued endorsement.
MAP reviewed a revised version of this measure
that would expand the cohort of patients included
in the measure to include patients with a primary
diagnosis of aspiration pneumonia and sepsis. The
MAP noted that pneumonia mortality remains an
important area of hospital quality and this
expanded measure could potentially reduce coding
biases. This high-impact fully specified, tested
and endorsed outcome measure is already in use in
several public and private programs including IQR.
- Workgroup Recommendation: Conditional
support
|
|
Measures for
Discussion: Ambulatory Surgical Centers Quality Reporting
Program |
|
Programs under consideration: Ambulatory
Surgical Centers Quality Reporting Program
|
|
- Ambulatory surgery patients with appropriate
method of hair removal (MUC ID: E0515)
- Description: Percentage of ASC admissions
with appropriate surgical site hair removal. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP did not support
this measure since this measure is topped out with
limited performance variation among providers.
Measures of appropriate hair removal have been
removed from IQR. This measure is not in, nor
planned to be, in another program.
- Workgroup Recommendation: Do not
support
|
|
Measures for
Discussion: Medicare and Medicaid EHR Incentive Program for
Hospitals and Critical Access Hospitals (CAHs) |
|
Programs under consideration: Medicare
and Medicaid EHR Incentive Program for Hospitals and
Critical Access Hospitals (CAHs)
|
|
- Adverse Drug Events: - Inappropriate Renal Dosing
of Anticoagulants (MUC ID: X3323)
- Description: Percentage of patient-drug
days with administration of anticoagulants
requiring renal dosing with at least one error in
renal dosing (Comprehensive
Measure Information)
- Public comments received: 5
- Workgroup Rationale: MAP members agreed
that this measure addresses a critical gap in
adverse drug events. Anticoagulants are a high
risk class of drugs that should be administered
carefully to renal patients, for whom the effects
of many drugs differ from non-renal patients. MAP
encouraged further development of this measure at
the facility level, testing, and submission to NQF
for endorsement. MAP encouraged the developers to
fully specify this as an e-Measure, and NQF should
review the e-measure for endorsement. This measure
is also under review for the Hospital Inpatient
Quality Reporting program.
- Workgroup Recommendation: Encourage
continued development
- Perinatal Care Cesarean section (PC O2)
Nulliparous women with a term, singleton baby in
vertex position delivered by cesarean section (MUC
ID: X1970)
- Description: This measure assesses the
number of nulliparous women with a term, singleton
baby in a vertex position who are delivered by a
cesarean section. PC O2 is also 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). (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP encouraged
continued development of a maternal/child health
disparities sensitive outcome e-measure. Members
noted that this measure is included in the MAP
Safety Family of Measures and also under review
for the Medicare and Medicaid EHR Incentive
Program for Hospitals and Critical Access
Hospitals program. The original specification is
NQF-endorsed (0471 – PC-02 Cesarean Section);
however this version of the measure is not fully
specified as an e-Measure and has not been
reviewed as an e-Measure for endorsement.
- Workgroup Recommendation: Encourage
continued development
- Timely Evaluation of High-Risk Individuals in the
Emergency Department (MUC ID: X1234)
- Description: Median time from emergency
department (ED) arrival to provider evaluation for
individuals triaged at the two highest levels
based on a five-level triage system (e.g., triaged
as “immediate” or “emergent”). (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: MAP has previously
stressed the importance of ED throughput measures
as important markers of efficiency and safety
which can dramatically impact patient
experience.This measure in particular would
address severely ill patients being admitted to
the ED. The MAP encouraged continued development
of this e-measure it may have the potential to
capture important clinical data. This measure is
also under review for the Hospital Inpatient
Quality Reporting program.
- Workgroup Recommendation: Encourage
continued development
|
|
Measures for
Discussion: Inpatient Psychiatric Facilities Quality
Reporting Program |
|
Programs under consideration: Inpatient
Psychiatric Facilities Quality Reporting Program
|
|
- Timely Transmission of Transition Record
(Discharges from an Inpatient Facility to Home/Self
Care or Any Other Site of Care) (MUC ID: E0648)
- Description: Percentage of patients,
regardless of age, discharged from an inpatient
facility (e.g., hospital inpatient or observation,
skilled nursing facility, or rehabilitation
facility) to home or any other site of care for
whom a transition record was transmitted to the
facility or primary physician or other health care
professional designated for follow-up care within
24 hours of discharge (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP was supportive
of this measure and noted that this fully
specified and tested NQF-endorsed process measure
contributes to the efficient use of measurement
resources and addresses a critical program
objective and is highly impactful to patients by
improving person-centered by facilitating care
coordination and has the potential to reduce
readmission. While the group was supportive, they
did note caution since this measure may be
duplicative of an existing measure, HBIPS-7 Post
Discharge Continuing Care Plan Transmitted to Next
Level Care Provider upon Discharge, which is
developed and specified for psychiatric
facilities. Several members of the MAP encouraged
a selection of a best in class measure or a
harmonized metric by an appropriate Standing
Committee between this measure and HBIPS-7 for the
purposes for reporting and accreditation. Further,
members also noted that this measure should be
specified for use in all acute-care settings
facilities, as appropriate.
- Workgroup Recommendation:
Support
|
|
Measures for
Discussion: Hospital Readmission Reduction Program |
|
Programs under consideration: Hospital
Readmission Reduction Program
|
|
- Hospital 30-day, all-cause, risk-standardized
readmission rate (RSRR) following pneumonia
hospitalization (MUC ID: E0506)
- Description: The measure estimates a
hospital-level risk-standardized readmission rate
(RSRR) for patients discharged from the hospital
with a principal diagnosis of pneumonia. The
outcome is defined as unplanned readmission for
any cause within 30 days of the discharge date for
the index admission. A specified set of planned
readmissions do not count as readmissions. The
target population is patients 18 and over. CMS
annually reports the measure for patients who are
65 years or older and are either enrolled in
fee-for-service (FFS) Medicare and hospitalized in
non-federal hospitals or are hospitalized in
Veterans Health Administration (VA) facilities. (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP supported a
revised version of the measure that would expand
the cohort of patients included in the measure to
include patients with a primary diagnosis of
aspiration pneumonia for use in HRRP. While MAP
members agreed that this is a high-impact outcome
measure, part of the MAP Safety Family of
Measures, and in use in several public and private
programs, they did express caution. The MAP noted
that this measure should be considered for SDS
adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual
relationship between SDS factors and pneumonia
readmissions, and endorsed with appropriate SDS
adjustment as determined by NQF standing
committees. MAP also cautioned that CMS carefully
implement updated versions of measures to minimize
confusion among providers, consumers, and
purchasers trying to understand the results of the
measure and make decisions based off of these
results.
- Workgroup Recommendation:
Support
|
|
Measures for
Discussion: Hospital-Acquired Condition (HAC) Reduction
Program |
|
Programs under consideration: Hospital-Acquired
Condition (HAC) Reduction Program
|
|
- National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI)
Outcome (MUC ID: S0138)
- Description: CAUTI can be minimized by a
collection of prevention efforts. These include
reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters
to the patient´s leg to avoid bladder and urethral
trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic
technique for urinary catheter insertion. These
efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized
standard for HAI monitoring, leads to improved
patient outcomes and provides a mechanism for
identifying improvements and quality efforts. (Comprehensive
Measure Information)
- Public comments received: 9
- Workgroup Rationale: MAP supported the
implementation of an updated version of this
measure currently in the HAC Reduction Program.
This update was recently reviewed and recommended
by the NQF Safety Standing Committee. Implementing
this updated measure would extend the measure to
hospital settings outside the ICU and add another
risk adjustment methodology. The two risk
adjustment methodologies are: Standardized
Infection Ratio (SIR) uses a stratification
approach to compare CAUTIs incidence rates. For
example, the stratification can be by the
hospital’s patient care location as the predicted
number of CAUTIs in a medical ICU may be different
then a general medical/surgical unit. Adjusted
Ranking Metric (ARM) uses a more complex Bayesian
estimation technique to account for the small
sample sizes that may be present in the strata
described in the SIR above. To adjust for this
potentially low precision and/or reliability due
to sample size, a statistical adjustment is made
to the numerator. While the group was supportive
they noted caution that the measure should be
publically report prior to use in a payment or
penalty program to allow for some experience in
the measure for CMS and providers. Expanding the
measure from the ICU to other locations in the
hospital significantly adjusts the measure and
experience is needed. MAP also acknowledged
concerns raised by providers specializing in the
treatment of spinal cord injuries and encouraged
further consideration on the trade-offs of
including these patients in this measure
population. Finally, several MAP members noted
that the ARM calculation is very difficult to
replicate without coefficients from CDC and urged
CDC and CMS to make all elements of the
calculation transparent.
- Workgroup Recommendation: Support
- National Healthcare Safety Network (NHSN) Central
line-associated Bloodstream Infection (CLABSI)
Outcome (MUC ID: S0139)
- Description: CLABSI can be minimized
through proper management of the central line.
Efforts to improve central line insertion and
maintenance practices, with early discontinuance
of lines are recommended. These efforts result in
decreased morbidity and mortality and reduced
healthcare costs. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP was supportive
of the implementation of an updated version of a
measure currently in the HAC Reduction Program.
This update was recently reviewed and recommended
by the NQF Safety Standing Committee. Implementing
this updated measure would extend the measure to
hospital settings outside the ICU and add another
risk adjustment methodology. The two risk
adjustment methodologies are: Standardized
Infection Ratio (SIR) uses a stratification
approach to compare CLABSI incidence rates. For
example, the stratification can be by the
hospital’s patient care location as the predicted
number of CLABSIs in a medical ICU may be
different then a NICU. Adjusted Ranking Metric
(ARM) uses a more complex Bayesian estimation
technique to account for the small sample sizes
that may be present in the strata described in the
SIR above. To adjust for this potentially low
precision and/or reliability due to sample size, a
statistical adjustment is made to the numerator.
MAP noted that expanding the measure from the ICU
to other locations in the hospital significantly
adjusts the measure and measure use experience is
needed.
- Workgroup Recommendation:
Support
|
|
Measures for
Discussion: PPS-Exempt Cancer Hospital Quality Reporting
Program |
|
Programs under consideration: PPS-Exempt
Cancer Hospital Quality Reporting Program
|
|
- National Healthcare Safety Network (NHSN)
Facility-wide Inpatient Hospital-onset
Methicillin-resistant Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure (MUC ID: E1716)
- Description: Standardized infection ratio
(SIR) of hospital-onset unique blood source MRSA
Laboratory-identified events (LabID events) among
all inpatients in the facility (Comprehensive
Measure Information)
- Public comments received: 2
- Workgroup Rationale: The measure was
conditionally supported, pending? stratification
for cohorts of cancer patients (BMT, Hematologic,
and Solid tumor). This measure addresses the
critical program objectives of PPS-Exempt Cancer
HQPR, has been tested for the appropriate level of
analysis, is NQF endorsed, and supports alignment
across programs. This measure would promote
alignment between programs assessing general acute
care and cancer hospitals (IQR and PCHQR). This
measure is included in the MAP Safety Family of
Measures.
- Workgroup Recommendation: Conditional
support
|
| |
|
|
This section of the meeting finalizes the hospital
workgroup recommendations for:
|
| 11:05 am |
Opportunity for Public Comment |
|
|
| 11:20 am |
|
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| |
|
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The Medicare Shared Savings Program was examined by three
MAP workgroups (clinician, hospital, and post-acute
care/long-term care). This section synthesizes the themes
raised across the three workgroup discussions.
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Programs under consideration: Medicare
Shared Savings Program
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- Payment-Standardized Medicare Spending Per
Beneficiary (MSPB) (MUC ID: E2158)
- Description: The MSPB Measure assesses
the cost of services performed by hospitals and
other healthcare providers during an MSPB
hospitalization episode, which comprises the
period immediately prior to, during, and following
a patient’s hospital stay. Beneficiary populations
eligible for the MSPB calculation include Medicare
beneficiaries enrolled in Medicare Parts A and B
who were discharged from short-term acute
hospitals during the period of performance.[Note:
Description differs from older version of measure
listed on QPS.] (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP was supportive
of this cost/resource measure that captures
services delivered between 3 days prior to an
acute inpatient hospital admission through the
period 30 days after discharge. As a MAP
identified high-value measurement area, this
measure seeks incentive hospitals to improve care
coordination and reduce fragmentation across the
health care delivery system. MAP noted that this
measure also promotes alignment across quality
measurement reporting programs since it is used in
the Hospital Inpatient Quality Reporting program,
and the Hospital Value-Based Purchasing program.
This measure is included in the MAP Affordability
Family of Measures along with MAP Duals Family of
Measures.
- Workgroup Recommendation: Support
- 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 (Comprehensive
Measure Information)
- Public comments received: 3
- Workgroup Rationale: MAP encourages
continued development of these care coordination
measures (X3283, X3302,X3466, X3465) for MSSP.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 4
- Workgroup Rationale: MAP encourages
continued development of this high-value outcome
measure for a procedure frequently performed in
the Medicare population. MAP hopes this measure
will be available for use very soon.
- Workgroup Recommendation: Encourage
continued development
- 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. (Comprehensive
Measure Information)
- Public comments received: 1
- Workgroup Rationale: MAP encourages
continued development of this measure for patients
with osteoarthritis-a prevalent condition in the
Medicare population.
- Workgroup Recommendation: Encourage
continued development
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This section of the meeting finalizes the workgroup
recommendations for: Medicare
Shared Savings Program
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| 12:15 pm |
Opportunity for Public Comment |
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| 12:30 pm |
Working Lunch |
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| 1:30 pm |
Round-Robin Discussion: Improving
MAP’s Processes |
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| 2:30 pm |
Opportunity for Public Comment |
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| 2:45 pm |
Closing Remarks |
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| 3:00 pm |
Adjourn |
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Appendix A: Measure Information
Measure Index
Ambulatory Surgical Centers Quality Reporting Program
End-Stage Renal Disease Quality Incentive Program
Physician Feedback
Hospital-Acquired Condition (HAC) Reduction Program
Home Health Quality Reporting Program
Hospital Readmission Reduction Program
Hospital Value-Based Purchasing Program
Inpatient Psychiatric Facilities Quality Reporting Program
Inpatient Quality Reporting Program
- Adverse
Drug Events: - Inappropriate Renal Dosing of Anticoagulants
(Workgroup Recommendation: Encourage continued development; Public
comments received:4;
MUC ID: X3323)
- Cardiac
Rehabilitation Patient Referral From an Inpatient Setting
(Workgroup Recommendation: Conditional support; Public comments
received:11;
MUC ID: E0642)
- Cellulitis
Clinical Episode-Based Payment Measure (Workgroup
Recommendation: Conditional support; Public comments received:3;
MUC ID: X0354)
- Falls
with injury (Workgroup Recommendation: Conditional support;
Public comments received:15;
MUC ID: E0202)
- Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure (Workgroup
Recommendation: Conditional support; Public comments received:4;
MUC ID: X0355)
- Hip
Replacement/ Revision Clinical Episode-Based Payment Measure
(Workgroup Recommendation: No longer under consideration by CMS;
Public comments received:1;
MUC ID: X0356)
- Hospital
30-day, all-cause, risk-standardized mortality rate (RSMR)
following pneumonia hospitalization (Workgroup Recommendation:
Conditional support; Public comments received:4;
MUC ID: E0468)
- Hospital
30-day, all-cause, risk-standardized readmission rate (RSRR)
following pneumonia hospitalization (Workgroup Recommendation:
Conditional support; Public comments received:6;
MUC ID: E0506)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care
following acute myocardial infarction (AMI) hospitalization
(Workgroup Recommendation: Conditional support; Public comments
received:6;
MUC ID: X3728)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care
following heart failure hospitalization (Workgroup
Recommendation: Conditional support; Public comments received:7;
MUC ID: X3722)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care
following pneumonia hospitalization (Workgroup Recommendation:
Conditional support; Public comments received:6;
MUC ID: X3727)
- Hospital-level,
risk-standardized payment associated with an episode of care for
primary elective total hip and/or total knee arthroplasty
(THA/TKA) (Workgroup Recommendation: Conditional support; Public
comments received:3;
MUC ID: X3620)
- Hospital-Wide
All-Cause Unplanned Readmission Hybrid eMeasure (Workgroup
Recommendation: Encourage continued development; Public comments
received:7;
MUC ID: X3701)
- Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure
(Workgroup Recommendation: Conditional support; Public comments
received:5;
MUC ID: X0351)
- Knee
Replacement/ Revision Clinical Episode-Based Payment Measure
(Workgroup Recommendation: No longer under consideration by CMS;
Public comments received:2;
MUC ID: X0352)
- National
Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract
Infection (CAUTI) Outcome (Workgroup Recommendation: Support;
Public comments received:6;
MUC ID: S0138)
- National
Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome (Workgroup
Recommendation: Support; Public comments received:1;
MUC ID: S0139)
- Nursing
Hours per Patient Day (Workgroup Recommendation: Conditional
support; Public comments received:8;
MUC ID: E0205)
- Paired
Measures 0702 and 0703; Intensive Care Unit (ICU) Length-of-Stay
(LOS) and Intensive Care: In-hospital mortality rate (Workgroup
Recommendation: No longer under consideration by CMS; Public comments
received: 0; MUC ID: E2104)
- Participation
in a Patient Safety Culture Survey (Workgroup Recommendation:
Support; Public comments received:3;
MUC ID: X3689)
- Patient
fall rate (Workgroup Recommendation: Conditional support; Public
comments received:12;
MUC ID: E0141)
- Perinatal
Care Cesarean section (PC O2) Nulliparous women with a term,
singleton baby in vertex position delivered by cesarean section
(Workgroup Recommendation: No longer under consideration by CMS;
Public comments received:4;
MUC ID: X1970)
- Proportion
of Patients Hospitalized with AMI that have a Potentially Avoidable
Complication (during the Index Stay or in the 30-day Post-Discharge
Period) (Workgroup Recommendation: Conditional support; Public
comments received:8;
MUC ID: E0704)
- Proportion
of Patients Hospitalized with Pneumonia that have a Potentially
Avoidable Complication (during the Index Stay or in the 30-day
Post-Discharge Period) (Workgroup Recommendation: Conditional
support; Public comments received:8;
MUC ID: E0708)
- Proportion
of Patients Hospitalized with Stroke that have a Potentially
Avoidable Complication (during the Index Stay or in the 30-day
Post-Discharge Period) (Workgroup Recommendation: Conditional
support; Public comments received:9;
MUC ID: E0705)
- Skill
mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse
[LVN/LPN], unlicensed assistive personnel [UAP], and contract)
(Workgroup Recommendation: Conditional support; Public comments
received:16;
MUC ID: E0204)
- Spine
Fusion/ Refusion Clinical Episode-Based Payment Measure
(Workgroup Recommendation: Conditional support; Public comments
received:6;
MUC ID: X0353)
- Timely
Evaluation of High-Risk Individuals in the Emergency Department
(Workgroup Recommendation: Encourage continued development; Public
comments received:2;
MUC ID: X1234)
- Transfusion
Reaction (PSI 16) (Workgroup Recommendation: No longer under
consideration by CMS; Public comments received: 0; MUC ID:
E0349)
Inpatient Rehabilitation Facilities Quality Reporting
Program
Long-Term Care Hospitals Quality Reporting Program
Medicare Shared Savings Program
Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals
Medicare and Medicaid EHR Incentive Program for Hospitals and
Critical Access Hospitals (CAHs)
Hospital Outpatient Quality Reporting Program
PPS-Exempt Cancer Hospital Quality Reporting Program
Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier
Skilled Nursing Facilities Value-Based Purchasing
Value-Based Payment Modifier
Full Measure Information
| Advance Care Plan
(Program: Ambulatory Surgical Centers Quality Reporting
Program; MUC ID: E0326) |
Measure Specifications
- NQF Number (if applicable): 0326
- Description: Percentage of patients aged 65 years and
older who have an advance care plan or surrogate decision maker
documented in the medical record or documentation in the medical
record that an advance care plan was discussed but the patient did
not wish or was not able to name a surrogate decision maker or
provide an advance care plan. [Description differs from posted MUC
list based on NQF staff analysis]
- Numerator statement: Patients who have an advance care
plan or surrogate decision maker documented in the medical record or
documentation in the medical record that an advance care plan was
discussed but patient did not wish or was not able to name a
surrogate decision maker or provide an advance care plan. [Numerator
differs from posted MUC list based on NQF staff
analysis]
- Denominator statement: All patients aged 65 years and
older.
- Exclusions: None
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Administrative Claims, EHR
- Measure type: Process
- Steward: National Committee for Quality Assurance
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: This measure requires evaluation and
management CPT codes which are not payable in the ASC. MAP noted that
the measure would need to be respecified, tested, and endorsed for
the ASC setting prior to use in this program.
- Public comments received: 2
Rationale for measure provided by HHS
This measure would be
consistent with a legislative mandate affecting Medicare beneficiaries,
the Patient Self Determination Act (PSDA), approved in 1990. The act
requires that beneficiaries be informed about their rights to
self-determination and the use of advance directives, and identifies
particular facilities accountable for providing the information. Despite
this, a recent cancer research study had found that most patients had not
spoken extensively to health professionals or close persons about the
future. Furthermore, a recent meta-analysis found that awareness of
patients´ and surrogates´ decision-making characteristics and
communication styles can help clinicians identify potential barriers and
variations in patterns of communication. To that end, the authors
contend that initial and ongoing assessments of patients´ and surrogates´
communication style and characteristics must be incorporated into the
plan of care (Melhado 2011). A cross-sectional study out of Oklahoma
found that among community dwelling older persons, a living will is a
positive first step towards healthcare planning and designating a
power of attorney. They also found that the state’s effort to increase
the use of advance directives among older residents was successful,
indicating that organizations have the power to influence people with
respect ACP (Mcauley 2008). An observational study from La Crosse County,
Wisconsin found that a system for ACP can be managed in a geographic
region so that, at the time of death, almost all adults have an advance
care plan that is specific and available and treatment is consistent
with their plan. The data from this study suggest that quality efforts
have improved the prevalence, clarity, and specificity of ACPs (Hammes
2010). Barnes KA, Barlow CA, Harrington J, Ornadel K, Tookman A, King M,
& Jones L. (2011). Advance Care Planning Discussions in Advanced
Cancer: Analysis of Dialogues Between Patients and Care Planning
Mediators. Palliative & Supportive Care;9(1):73-9. Basanta WE.
(2002). Advance Directives and Life-Sustaining Treatment: A Legal
Primer. Hematology/Oncology Clinics of North America;16(6):1381-96.
Garand L, Drew MA, Lingler JH, & DeKosky ST. (2011). Incidence and
Predictors of Advance Care Planning Among Persons With Cognitive
Impairment. American Journal of Geriatric Psychiatry;18(8):712-20. Hammes
BJ, Rooney BL, & Gundrum JD. (2010). A Comparative, Retrospective,
Observational Study of the Prevalence, Availability, and Specificity
of Advance Care Plans in a County that Implemented an Advance Care
Planning Microsystem. Journal of the American Geriatrics
Society;58(7):1249-55. Mcauley WJ, McCutheon ME, & Travis SS. (2008).
Advance Directives for Health Care Among Older Community Residents.
Journal of Health & Human Services Administration, 30(4), 402-419.
Melhado LW & Byers JF. (2011). Patients’ and Surrogates’
Decision-Making Characteristics Withdrawing, Withholding, and Continuing
Life-Sustaining Treatments. Journal of Hospice & Palliative
Nursing;13(1):16-28. Sampson EL, Jones L, Thune-Boyle IC, Kukkastenvehmas
R, King M, Leurent B, Tookman A, & Blanchard MR. Palliative
assessment and advance care planning in severe dementia: An exploratory
randomized controlled trial of a complex intervention. Palliative
Care;25(3):197-209. Sanders A, Schepp M, & Baird M. (2011). Partial
do-not-resuscitate orders: A Hazard to Patient Safety and Clinical
Outcomes? Critical Care Medicine;39(1):14-8. Tung EE, Vickers KS, Lackore
K, Cabanela R, Hathaway J, & Chaudhry R. (2011). Clinical
Decision Support Technology to Increase Advance Care Planning in the
Primary Care Setting. American Journal of Hospice and Palliative
Medicine;28(4):230-5.
Measure Specifications
- NQF Number (if applicable): 0515
- Description: Percentage of ASC admissions with appropriate
surgical site hair removal.
- Numerator statement: ASC admissions with surgical site
hair removal with a razor or clippers from the scrotal area, or with
clippers or depilatory cream from all other surgical
sites
- Denominator statement: All ASC admissions with surgical
site hair removal
- Exclusions: ASC admissions who perform their own hair
removal
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Paper Medical Record
- Measure type: Process
- Steward: ASC Quality Collaboration
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP did not support this measure
since this measure is topped out with limited performance variation
among providers. Measures of appropriate hair removal have been
removed from IQR. This measure is not in, nor planned to be, in
another program.
- Public comments received: 1
Rationale for measure provided by HHS
The literature
regarding preoperative hair removal has been systematically reviewed
twice, once by Kjonniksen et al in 2002 and again by Tanner et al in
2007. Three randomized controlled trials (Alexander et al 1983, Balthazar
et al 1983, Ko et al 1992) compared the rates of infection at the
surgical site when hair removal at the site was performed with clippers
or with razors. A statistically significant difference in infection
rates in the pooled results (Tanner et al 2007) was seen, with 2.8% of
the patients who were shaved developing a surgical site infection
compared with 1.4% rate of surgical site infection in the patients who
were clipped. Additional randomized controlled trials (Court-Brown 1981,
Powis et al 1976, Seropian 1971, Thur de Koos 1983) have demonstrated
that patients were more likely to develop a surgical site infection when
shaved as compared to having hair removal with a depilatory.
Observational studies have suggested that no hair removal is less likely
to result in surgical site infection, but this has not been confirmed in
randomized controlled trials. The HICPAC/CDC Guideline for
Prevention of Surgical Site Infection (Mangram at al 1999), the
Association of Operating Room Nurses Recommended Practices for
Preoperative Patient Skin Antisepsis (AORN 2002) and the SHEA/IDSA
Strategies to Prevent Surgical Site Infections in Acute Care Hospitals
(Anderson et al 2008) are consistent with the intent of this measure.
Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The
influence of hair-removal methods on wound infections. Arch Surg. 1983
Mar;118(3):347-52. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K,
Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN,
Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L,
Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R,
Yokoe DS. Strategies to prevent surgical site infections in acute care
hospitals. Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61.
Association of Operating Room Nurses. Recommended practices for skin
preparation of patients. AORN J. 2002 Jan;75(1):184-7. Balthazar ER, Colt
JD, Nichols RL. Preoperative hair removal: a random prospective study of
shaving versus clipping. South Med J. 1982 Jul;75(7):799-801.
Court-Brown CM. Preoperative skin depilation and its effect on
postoperative wound infections. J R Coll Surg Edinb. 1981
Jul;26(4):238-41. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L.
Preoperative hair removal--a systematic literature review. AORN J. 2002
May;75(5):928-38, 940. Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH.
Effects of shaving methods and intraoperative irrigation on suppurative
mediastinitis after bypass operations. Ann Thorac Surg. 1992
Feb;53(2):301-5. Powis SJ, Waterworth TA, Arkell DG. Preoperative skin
preparation: clinical evaluation of depilatory cream. Br Med J. 1976 Nov
13;2(6045):1166-8. Seropian R, Reynolds BM. Wound infections after
preoperative depilatory versus razor preparation. Am J Surg. 1971
Mar;121(3):251-4. Tanner J, Moncaster K, Woodings D. Preoperative hair
removal to reduce surgical site infection. Cochrane Database Syst Rev.
2006 Jul 19;3:CD004122. Thur de Koos P, McComas B. Shaving versus skin
depilatory cream for preoperative skin preparation. A prospective study
of wound infection rates. Am J Surg. 1983 Mar;145(3):377-8.
| Normothermia
Outcome (Program: Ambulatory Surgical Centers Quality
Reporting Program; MUC ID: X3719) |
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This measure evaluates whether patients
having surgical procedures under general or neuraxial anesthesia of
60 minutes or more in duration are normothermic within 15 minutes of
arrival in PACU
- Numerator statement: Surgery patients with a body
temperature equal to or greater than 96.8 Fahrenheit/36 Celsius
recorded within fifteen minutes of Arrival in PACU
- Denominator statement: All patients, regardless of age,
undergoing surgical procedures under general or neuraxial anesthesia
of greater than or equal to 60 minutes duration
- Exclusions: None
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Paper Medical Record
- Measure type: Intermediate Outcome
- Steward: ASC Quality Collaboration
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending the
completion of reliability testing and NQF endorsement. ??MAP
supported this measure conditional on completion of reliability
testing, review and endorsement by NQF. The MAP agreed that this
measure is highly impactful and meaningful to patients.
Anesthetic-induced thermoregulatory impairment may cause
perioperative hypothermia, which is associated with adverse outcomes
including significant morbidity (decrease in tissue metabolic rate,
myocardial ischemia, surgical site infections, bleeding diatheses,
prolongation of drug effects) and mortality. As an intermediate
outcome measure, this workgroup agreed that this measure moves
towards an outcome measure that fills the workgroup identified gap of
anesthesia related complications.
- Public comments received: 1
Rationale for measure provided by HHS
Anesthetic-induced
thermoregulatory impairment may cause perioperative hypothermia, which is
associated with adverse outcomes.
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: "When you arrived at
this facility on the day of your procedure, did the check-in process
run smoothly?" P2: "Was the facility clean?" P3: "Were the clerks and
receptionists at the facility as helpful as you thought they should
be?" P4: "Did the clerks and receptionists at the facility treat you
with courtesy and respect?" P5: "Did the doctors, nurses and other
staff treat you with courtesy and respect?" P6: "Did the doctors,
nurses and other staff make sure you were as comfortable as
possible?"
- Numerator statement: Proportions of top box responses
(YES) are calculated for each question. The proportions are then
averaged over all questions in the multi-item measure.
(P1+P2+P3+P4+P5+P6)/6
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The outpatient/ambulatory surgery
patient experience of care survey asks five specific questions
regarding the communication of discharge instructions and follow-up
after discharge. MAP noted that this is a high impact measure that
will improve both quality and efficiency of care and be meaningful to
consumers. Members noted that this measure should be reviewed in
light of other instruments and implementers should seek to minimize
burden on patients who will be asked to complete this survey and
providers who are asked to administer this survey.
- Public comments received: 2
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: “Did your doctor or
anyone from the facility give you all the information you needed
about your procedure?” P2: “Did your doctor or anyone from the
facility give you easy to understand instructions about getting ready
for your procedure?” P3: “Did the doctors, nurses and other staff
explain things about your procedure in a way that was easy for you to
understand?” P4 “Did your doctor or anyone from the facility explain
the process of giving anesthesia in a way that was easy to
understand? P5: “Did your doctor or anyone from the facility explain
the possible side effects of the anesthesia in a way that was easy
to understand?
- Numerator statement: Proportions of top box responses
(YES, YES DEFINITELY) are calculated for each question. P4 and P5
count only those who had anesthesia. These proportions are then
averaged over all questions in the multi-item measure. (P1 + P2 + P3
+ P4 + P5)/5
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The outpatient/ambulatory surgery
patient experience of care survey asks five specific questions
regarding the communication of discharge instructions and follow-up
after discharge. MAP noted that this is a high impact measure that
will improve both quality and efficiency of care and be meaningful to
consumers. Members noted that this measure should be reviewed in
light of other instruments and implementers should seek to minimize
burden on patients who will be asked to complete this survey and
providers who are asked to administer this survey.
- Public comments received: 2
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: “Discharge
instructions include things like symptoms you should watch out for
after your procedure, instructions about your medicines, and home
care. Before you left the facility, did you receive written discharge
instructions?” P2: “Did your doctor or anyone from the facility
prepare you for what to expect during your recovery?” P3: “Ways to
control pain can include prescription medicine, over-the-counter pain
relievers or ice packs, for example. Did your doctor or anyone from
the facility give you information about what to do if you had pain
as a result of your procedure” (of those that had pain as a
result of the procedure). P4: “Before you left, did your doctor or
anyone from the facility give you information about what to do if you
had nausea or vomiting” (of those that had either nausea or vomiting
as a result of either your procedure or anesthesia). P5: “Before you
left, did your doctor or anyone from the facility give you
information about what to do if you had bleeding as a result of your
procedure” (of those that had bleeding as a result of the procedure).
P6: “Possible signs of infection include fever, swelling, heat,
drainage or redness. Before you left, did your doctor or anyone from
the facility give you information about what to do if you had
possible signs of infection (of those having signs of infection as a
result of the procedure).
- Numerator statement: Proportions of top box responses
(YES, YES DEFINITELY) are calculated for each question. These
proportions are then averaged over all questions in the multi-item
measure. (P1 + P2 + P3 + P4 + P5+ P6)/6
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The outpatient/ambulatory surgery
patient experience of care survey asks five specific questions
regarding the communication of discharge instructions and follow-up
after discharge. MAP noted that this is a high impact measure that
will improve both quality and efficiency of care and be meaningful to
consumers. Members noted that this measure should be reviewed in
light of other instruments and implementers should seek to minimize
burden on patients who will be asked to complete this survey and
providers who are asked to administer this survey.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Survey Question: Using any number from 0 10
10, where 0 is the worst facility possible and 10 is the best
facility possible, what number would you use to rate this
facility?
- Numerator statement: Number of respondents answering 9 or
10
- Denominator statement: Number of respondents answering the
survey question
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The outpatient/ambulatory surgery
patient experience of care survey asks five specific questions
regarding the communication of discharge instructions and follow-up
after discharge. MAP noted that this is a high impact measure that
will improve both quality and efficiency of care and be meaningful to
consumers. Members noted that this measure should be reviewed in
light of other instruments and implementers should seek to minimize
burden on patients who will be asked to complete this survey and
providers who are asked to administer this survey.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
| O/ASPECS
Recommend (Program: Ambulatory Surgical Centers
Quality Reporting Program; MUC ID: X3703) |
Measure Specifications
- NQF Number (if applicable):
- Description: Survey question: Would you recommend this
facility to your friends and family? Response options: Definately no,
Probably no, Probably yes, Definately yes.
- Numerator statement: Number of respondents answering
“Definately yes”.
- Denominator statement: Number of respondents answering the
survey question
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The outpatient/ambulatory surgery
patient experience of care survey asks five specific questions
regarding the communication of discharge instructions and follow-up
after discharge. MAP noted that this is a high impact measure that
will improve both quality and efficiency of care and be meaningful to
consumers. Members noted that this measure should be reviewed in
light of other instruments and implementers should seek to minimize
burden on patients who will be asked to complete this survey and
providers who are asked to administer this survey.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This measure evaluates the number of cataract
surgery patients who have an unplanned anterior
vitrectomy
- Numerator statement: All cataract surgery patients who had
an unplanned anterior vitrectomy
- Denominator statement: All cataract surgery patients
- Exclusions: None
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Paper Medical Record
- Measure type: Outcome
- Steward: ASC Quality Collaboration
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending the
completion of reliability testing and NQF endorsement. MAP supported
this measure conditional on completion of reliability testing, review
and endorsement by NQF. The MAP agreed that this measure is highly
impactful and meaningful to patients. According to the National Eye
Institute report in 2002, more than half of US residents over 65
years have a cataract. Cataracts are a leading cause of blindness,
with more than 1.5 million cataract surgeries performed annually to
improve the vision of those with cataracts. An anterior
vitrectomy, the repair of a rupture in a mainly liquid portion of the
eye, is generally an unplanned complication of a cataract surgery.
MAP agreed that this is an outcome measure that fills the workgroup
identified priority gap of procedure complications.
- Public comments received: 3
Rationale for measure provided by HHS
Cataract surgery is a
commonly performed operation and should be associated with low
intra-operative morbidity.
Measure Specifications
- NQF Number (if applicable): 1919
- Description: The Cultural Competence Implementation
Measure is an organizational survey designed to assist healthcare
organizations in identifying the degree to which they are providing
culturally competent care and addressing the needs of diverse
populations, as well as their adherence to 12 of the 45 NQF-endorsed®
cultural competency practices prioritized for the survey. The target
audience for this survey includes healthcare organizations across a
range of health care settings, including hospitals, health plans,
community clinics, and dialysis organizations. Information from
the survey can be used for quality improvement, provide information
that can help health care organizations establish benchmarks and
assess how they compare in relation to peer organizations, and for
public reporting.
- Numerator statement: The target audience for this survey
includes health care organizations across a range of health care
settings, including hospitals, health plans, community clinics, and
dialysis organizations. The focus of the measure is the degree to
which health care organizations have adopted or implemented 12 of the
45 NQF-endorsed cultural competency preferred practices.
- Denominator statement: As mentioned above, the survey can
be used to measure adherence to 12 of the 45-NQF endorsed cultural
competence preferred practices. The survey could be used to focus on
a particular type of health care organization, or more broadly to
collect information across various organization types.
- Exclusions: None
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Process
- Steward: RAND Corporation
- Endorsement Status: Endorsed
Summary of workgroup deliberations: Consensus not reached.
Split between conditional support and do not support. MAP considered both
the outcome and reporting version of this measure, noting the reporting
version serves as an important first step towards implementing the
outcome measure. MAP recognized the importance of cultural competency but
raised concerns that this measure has limited testing in the dialysis
facility setting. While some members raised concerns about the burden
of this measure, CMS clarified that data would be collected through a
survey administered once per year per site. Other MAP members noted that
this measure addresses a critical program objective of expanding the
measure set to include cross-cutting aspects of care such as patient
engagement. Culturally competent care improves patient engagement. It
addresses the NQS priority of person and family engagement and is NQF
endorsed. While this measure is not publicly reported, it could be used
as a means of assessing whether standards for providing culturally
competent care are being met and specifically, the degree to which
healthcare organizations are adhering to the NQF-endorsed preferred
practices for providing culturally competent care.
Public comments received: 5
Preliminary Analysis of Measure
- Preliminary analysis result: Support
- Preliminary analysis summary: The measure addresses a
critical program objective of expanding the measure set to include
nonclinical aspects of care such as patient engagement. Culturally
competent care improves patient engagement. It addresses the NQS
priority of person and family engagement and is NQF endorsed. While
this measure is not publicly reported, it could be used as a means of
assessing whether standards for providing culturally competent care
are being met and specifically, the degree to which healthcare
organizations are adhering to the NQF-endorsed preferred practices
for providing culturally competent care.
- Does the measure address a critical program objective as
defined by MAP? Yes. This measure meets a critical program
objectiveto expand the measure set beyond dialysis procedures to
include nonclinical aspects of care such as patient
engagement. Culturally competent care is a
crucial aspect of patient engagement. Additionally
ther
- Measure development status: Fully developed
- Is the measure fully tested for the program's setting and
level of analysis? Yes. Tested in ?Dialysis Facilities
- Is the measure currently in use? Yes. This survey measure
is used for internal and external quality improvement purposes.
It is not currently in use for public reporting.
- Does a review of its performance history raise any
concerns? No. No data found.
- Does the measure promote alignment and parsimony? Yes.
This measure addresses the cross-cutting gap areas of Care
Coordination, Disparities, Patient and Family Engagement.
However, measure is not yet publicly reported; this is a structure
measure.
- Is the measure NQF endorsed for the program's setting and
level of analysis? Endorsed. Endorsed in 2012; due for Annual
Update 2014.
- Does the measure address a high-priority quality issue in
the dual eligible beneficiary population? No.
Rationale for measure provided by HHS
Numerous studies have
documented the existence of significant disparities in access to health
care, outcomes, and health status among racial and ethnic minorities.
Studies conducted across a variety of healthcare settings have found that
racial/ethnic minority patients as well as those with low
socioeconomic status or LEP report worse experiences of care, compared
with whites, those with higher socioeconomic status, and English
speakers. Growing evidence points to the fact that minority populations
tend to receive lower quality of care even when factors such as access,
health insurance, and income are taken into account. In short, racial and
ethnic minorities face disproportionately higher rates of disease,
disability, and mortality. For example, compared to whites, African
Americans have higher death rates from heart disease, diabetes, AIDS, and
cancer, and American Indians and Alaskan Natives have lower life
expectancies and higher rates of infant mortality. Despite the fact that
health care systems in the U.S. have improved over time, that racial and
ethnic disparities have been widely documented, and that numerous
attempts have been made to reduce or eliminate these disparities, they
continue to be widespread and pervasive. No doubt the causes of these
health disparities are the result of multiple factors including bias
(conscious or unconscious) on the part of the providers, differences in
patients’ expectations, miscommunication caused by cultural
differences, and organizational factors that impact the quality of
patient–provider interactions. However, there is also growing evidence
that a major contributor to healthcare disparities is a lack of
culturally competent care. Cultural competence can be defined as the
ongoing capacity of healthcare systems, organizations, and professionals
to provide diverse populations high quality care that is safe, patient
and family centered, evidence-based, and equitable. To be culturally
competent, health care providers have to employ various interpersonal and
organizational strategies to overcome or at the very least reduce
the barriers to access, communication, and understanding that stem from
racial, ethnic, cultural, and linguistic differences. Providing
culturally appropriate care has the potential to reduce disparities and
improve outcomes while at the same time improving patient satisfaction.
In recent years, more and more organizations have begun exploring ways to
improve cultural competency—that is, to ensure that diverse patient
populations receive high-quality care that is safe, patient and family
centered, evidence-based, and equitable. The National Quality Forum
(NQF), an organization dedicated to improving healthcare quality, aims to
promote culturally competent care, to reduce disparities, and to make
care more patient-centered by endorsing a comprehensive framework for
measuring and reporting cultural competency. It also endorsed a set of 45
preferred practices to provide culturally competent care. The framework
and practices were published in an NQF report titled, "A
Comprehensive Framework and Preferred Practices for Measuring and
Reporting Cultural Competency", and cover issues such as communication,
community engagement and workforce training, and providing healthcare
systems with practices they can implement to help reduce persistent
disparities in healthcare and create higher-quality, more
patient-centered care.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This reporting measure is designed to collect
data needed to score NQF #1919 in the ESRD QIP.
- Numerator statement: Facility reports Cultural Competency
survey data to CMS.
- Denominator statement: N/A
- Exclusions: None
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Process
- Steward: RAND Corporation
- Endorsement Status: Not Endorsed
Summary of workgroup deliberations: Consensus not reached.
Split between conditional support and do not support. MAP considered both
the outcome and reporting version of this measure, noting the reporting
version serves as an important first step towards implementing the
outcome measure. MAP recognized the importance of cultural competency but
raised concerns that this measure has limited testing in the dialysis
facility setting. While some members raised concerns about the burden
of this measure, CMS clarified that data would be collected through a
survey administered once per year per site. Other MAP members noted that
this measure addresses a critical program objective of expanding the
measure set to include cross-cutting aspects of care such as patient
engagement. Culturally competent care improves patient engagement. This
measure addresses the NQS priority of person and family
engagement.
Public comments received: 5
Preliminary Analysis of Measure
- Preliminary analysis result: Conditional support
- Preliminary analysis summary: This measure meets a
critical program objective previously identified by MAP that the
measure set should expand beyond dialysis procedures to include
nonclinical aspects of care such as patient engagement; culturally
competent care improves patient engagement.This measure would serve
as an important first step in assessing cultural competency. However,
MAP would encourage the rapid implementation of NQF
#1919.
- Does the measure address a critical program objective as
defined by MAP? Yes. This measure meets a critical program
objectiveto expand the measure set beyond dialysis procedures to
include nonclinical aspects of care such as patient
engagement.Culturally competent care is a crucial aspect of patient
engagement. Additionally there
- Measure development status: Fully developed
- Is the measure fully tested for the program's setting and
level of analysis? Yes. Tested in Dialysis Facilities
- Is the measure currently in use? No. Not currently used in
another CMS program. This is distinct from NQF # 1919 Cultural
Competency Implementation Measure in that it would be used to assess
the reporting of data contained in the survey, but not to assess
facility performance in the survey.
- Does the measure promote alignment and parsimony? Yes.
Addresses a critical program objective of expanding the measure set
to include nonclinical aspects of care such as patient engagement;
addresses the NQS priority of person and family engagement. The
measure is not yet in use in public 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
Numerous studies have
documented the existence of significant disparities in access to health
care, outcomes, and health status among racial and ethnic minorities.
Studies conducted across a variety of healthcare settings have found that
racial/ethnic minority patients as well as those with low
socioeconomic status or LEP report worse experiences of care, compared
with whites, those with higher socioeconomic status, and English
speakers. Growing evidence points to the fact that minority populations
tend to receive lower quality of care even when factors such as access,
health insurance, and income are taken into account. In short, racial and
ethnic minorities face disproportionately higher rates of disease,
disability, and mortality. For example, compared to whites, African
Americans have higher death rates from heart disease, diabetes, AIDS, and
cancer, and American Indians and Alaskan Natives have lower life
expectancies and higher rates of infant mortality. Despite the fact that
health care systems in the U.S. have improved over time, that racial and
ethnic disparities have been widely documented, and that numerous
attempts have been made to reduce or eliminate these disparities, they
continue to be widespread and pervasive. No doubt the causes of these
health disparities are the result of multiple factors including bias
(conscious or unconscious) on the part of the providers, differences in
patients’ expectations, miscommunication caused by cultural
differences, and organizational factors that impact the quality of
patient–provider interactions. However, there is also growing evidence
that a major contributor to healthcare disparities is a lack of
culturally competent care. Cultural competence can be defined as the
ongoing capacity of healthcare systems, organizations, and professionals
to provide diverse populations high quality care that is safe, patient
and family centered, evidence-based, and equitable. To be culturally
competent, health care providers have to employ various interpersonal and
organizational strategies to overcome or at the very least reduce
the barriers to access, communication, and understanding that stem from
racial, ethnic, cultural, and linguistic differences. Providing
culturally appropriate care has the potential to reduce disparities and
improve outcomes while at the same time improving patient satisfaction.
In recent years, more and more organizations have begun exploring ways to
improve cultural competency—that is, to ensure that diverse patient
populations receive high-quality care that is safe, patient and family
centered, evidence-based, and equitable. The National Quality Forum
(NQF), an organization dedicated to improving healthcare quality, aims to
promote culturally competent care, to reduce disparities, and to make
care more patient-centered by endorsing a comprehensive framework for
measuring and reporting cultural competency. It also endorsed a set of 45
preferred practices to provide culturally competent care. The framework
and practices were published in an NQF report titled, "A
Comprehensive Framework and Preferred Practices for Measuring and
Reporting Cultural Competency", and cover issues such as communication,
community engagement and workforce training, and providing healthcare
systems with practices they can implement to help reduce persistent
disparities in healthcare and create higher-quality, more
patient-centered care.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: Percentage of all patient months whose
delivered peritoneal dialysis dose was a weekly Kt/V urea of at least
1.7 within past four months (Adult >= 18) or 1.8 within past 6
months (pediatric <18).
- Numerator statement: Number of patient months in the
denominator whose delivered peritoneal dialysis was a weekly Kt/Vurea
of at least 1.7 within past four months (Adult >=18) or 1.8 within
past 6 months (pediatric <18).
- Denominator statement: To be included in the denominator
for a particular month, the patient must have been on dialysis for at
least 90 days.
- Exclusions: None
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims
- Measure type: Intermediate Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP noted that this measure meets critical program
objectives to include more outcome measures and measures applicable
to pediatric population in the set. Assessing the Kt/V is a way to
measure the dose of dialysis to ensure enough waste products are
removed from the patient's blood. This is a revision to NQF
#0318,Peritoneal Dialysis Adequacy Clinical Performance Measure
III-Delivered Dose of Peritoneal Dialysis Above Minimum. The measure
has been revised to address both adult and pediatric
populations.
- Public comments received: 5
Rationale for measure provided by HHS
This is a revision of
the existing NQF measure 0318. The measure has been revised to include
both adult and pediatric patients
Measure Specifications
- NQF Number (if applicable): N/A
- Description: Percentage of all patient months whose
delivered dose of dialysis (either hemo or peritoneal) met the
specified threshold. This measure is a composite of NQF #0318 and NQF
#0249.
- Numerator statement: Number of patients months in the
denominator whose delivered dose of dialysis met the specified
thresholds. The thresholds are as follows: • Hemodialysis (all ages):
Kt/V >= 1.2 • Peritoneal dialysis (pediatric): Kt/V >= 1.8
(within past 6 months) • Peritoneal dialysis (adult): Kt/V >= 1.7
(within past 4 months)
- Denominator statement: To be included in the denominator
for a particular month, patients need to meet the following
requirements that month: Peritoneal dialysis patients: All peritoneal
dialysis patients who have been on dialysis for at least 90 days.
Hemodialysis patients: Pediatric (<18 years old) in-center HD
patients who have been on dialysis for 90 days or more and dialyzing
thrice weekly, adult >= 18 years old) patients who have been on
dialysis for 90 days or more and dialyzing thrice weekly.
- Exclusions: Frequent hemodialysis patients >= 4 times
per week).
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims
- Measure type: Intermediate Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP noted that this measure meets a critical program
objective to explore whether clinically focused measures could be
combined into composites for assessing optimal care. Assessing the
Kt/V is a way to measure the dose of dialysis to ensure enough waste
products are removed from the patient's blood. This measure is a
composite of two existing Kt/V dialysis adequacy measures (#0318 and
#0249) and allows for assessment of all dialysis patients, avoiding
the exclusion of pediatric and peritoneal dialysis patients from
assessment in the program.
- Public comments received: 4
Rationale for measure provided by HHS
This measure is a
composite of two existing Kt/V dialysis adequacy measures. It permits
assessment for all dialysis patients included in those two measures with
a single composite score, avoiding the systematic exclusion of pediatric
and peritoneal dialysis patients from assessment in the QIP.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: Percentage of all patient months whose
average delivered dose of hemodialysis (calculated from the last
measurements of the month using the UKM or Daugirdas II formula) was
a spKt/V >= 1.2.
- Numerator statement: Number of patient months in
denominator whose delivered dose of hemodialysis (calculated from the
last measurements of the month using the UKM or Daugirdas II formula)
was a spKt/V >= 1.2.
- Denominator statement: To be included in the denominator
for a particular month, the patients must have been on dialysis for
at least 90 days and must be dialyzing thrice weekly during the
month.
- Exclusions: Pediatric home hemodialysis patients and
frequent hemodialysis patients >=4 times per week).
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims
- Measure type: Intermediate Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP noted that this measure meets critical program
objectives to include more outcome measures and measures applicable
to pediatric population in the set. Assessing the Kt/V is a way to
measure the dose of dialysis to ensure enough waste products are
removed from the patient's blood. This is a revision to NQF
#0249,Hemodialysis Adequacy Clinical Performance Measure III:
Hemodialysis Adequacy--HD Adequacy-- Minimum Delivered Hemodialysis
Dose. The measure has been revised to address both adult and
pediatric populations.
- Public comments received: 5
Rationale for measure provided by HHS
This is a revision of
the existing NQF measure 0249. The measure has been revised to include
both adult and pediatric patients
Measure Specifications
- NQF Number (if applicable): 0419
- Description: Percentage of specified visits for patients
aged 18 years and older for which the eligible professional attests
to documenting a list of current medications to the best of his/her
knowledge and ability. This list must include ALL prescriptions,
over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)
supplements AND must contain the medications’ name, dosage, frequency
and route of administration
- Numerator statement: Percentage of specified visits for
patients aged 18 years and older for which the eligible professional
attests to documenting a list of current medications to the best of
his/her knowledge and ability. This list must include ALL
prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain
the medications’ name, dosage, frequency and route of
administration[For reference, the numerator for endorsed measure on
QPS: Eligible professional attests to documenting, updating or
reviewing a patient´s current medications using all immediate
resources available on the date of the encounter. This list must
include ALL prescriptions, over-the counters, herbals,
vitamin/mineral/dietary (nutritional) supplements AND must contain
the medications’ name, dosages, frequency and routeNUMERATOR NOTE:
The eligible professional must document in the medical record they
obtained, updated, or reviewed a medication list on the date of the
encounter. Eligible professionals reporting this measure may document
medication information received from the patient, authorized
representative(s), caregiver(s) or other available healthcare
resources. G8427 should be reported if the eligible professional
documented that the patient is not currently taking any
medications.]
- Denominator statement: All visits occurring during the 12
month reporting period for patients aged 18 years and older on the
date of the encounter where one or more CPT or HCPCS codes are
reported on the claims submission for that encounter. All discussed
coding is listed in "2a1.7. Denominator Details" section below.[For
reference, denominator for endorsed measure from QPS: All visits for
patients aged 18 years and older]
- Exclusions: A patient is not eligible or excluded (B) from
the performance denominator (PD) if one or more of the following
reason exists: • Patient is in an urgent or emergent medical
situation where time is of the essence and to delay treatment would
jeopardize the patient’s health status.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of workgroup deliberations: Consensus not reached.
Split between conditional support and do not support. MAP considered both
the outcome and reporting version of this measure, noting the reporting
version serves as an important first step towards implementing the
outcome measure. MAP recognized the importance of medication
documentation but raised concerns about the feasibility of this measure.
MAP members noted that most prescriptions are written outside of the
dialysis facility and it can be challenging for providers to determine
what medications a patient is taking. Some members also expressed
concerns that this is a check box metric that will not improve medication
reconcilliation. However, other members noted that this measure addresses
a critical program objective that the measure set should expand beyond
dialysis procedures to include cross-cutting aspects of care, including
medication reconciliation. It also addresses the NQS priority of
safety and is included in the MAP duals family.
Public comments received: 4
Preliminary Analysis of Measure
- Preliminary analysis result: Conditional support
- Preliminary analysis summary: Support is conditional on
the measure being tested at the levels appropriate for ESRD
facilities.It addresses a critical program objective that the measure
set should expand beyond dialysis procedures to include non clinical
aspects of care, including medication reconciliation. It also
addresses the NQS priority of safety and is included in the MAP duals
family. It promotes alignment across federal programs as it is used
in clinician programs (e.g. PQRS, MU) and was recently finalized for
use in MSSP.
- Does the measure address a critical program objective as
defined by MAP? Yes. Meets a critical program objective
previously identified by MAP to expand the measure set beyond
dialysis procedures to include non clinical aspects of care,
including medication reconciliation.It is estimated that the rate of
adverse drug events in amb
- Measure development status: Fully developed
- Is the measure fully tested for the program's setting and
level of analysis? No. This measure is tested at the clinician
and national levels.
- Since no, could the measure be revised to use in the setting
or at level of analysis under consideration? Yes. Yes, as the
measure is specified for these settings: Ambulatory Care: Clinician
Office/Clinic, Behavioral Health/Psychiatric: Outpatient, Dialysis
Facility, Home Health, Other, Post Acute/Long Term Care Facility:
Inpatient Rehabilitation Facility, Post
- Is the measure currently in use? Yes. Meaningful Use Stage
2 (EHR Incentive Program) - Eligible Professionals; Physician
Feedback; Physician Quality Reporting System (PQRS)
- Does a review of its performance history raise any
concerns? No. Average 2011 Performance: 85.7% The measure is
in current operational use. Data collection for reliability testing
(medical record audits) is dependent on the provider. Specific
elements of the medical record must be requested to insure the audit
proce
- Does the measure promote alignment and parsimony? Yes.
This measure is in use in several federal programs, and fills a
gap in the area of inappropriate medication use. The measure is
included in the Duals Family of measures and was recently finalized
in the 2015 PFS final rule.
- Is the measure NQF endorsed for the program's setting and
level of analysis? Endorsed. Scheduled for NQF review in
2015.
- Does the measure address a high-priority quality issue in
the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS
Meets gap in
medication reconciliation measures and aligns with PQRS and MU. In 2005,
the rate of medication errors during hospitalization was estimated to be
52 per 100 admissions, or 70 per 1,000 patient days. Emerging research
suggests the scope of medication-related errors in ambulatory settings is
as or more extensive than during hospitalization. Ambulatory visits
result in a prescription for medication 50 to 70% of the time. One
study estimated the rate of adverse drug events (ADE) in the ambulatory
setting to be 27 per 100 patients. It is estimated that between 2004 and
2005, in the United States 701,547 patients were treated for ADEs in
emergency departments and 117,318 patients were hospitalized for injuries
caused by an ADE. Individuals aged 65 years and older are more likely
than any other population group to require treatment in the emergency
department for ADEs (American Medical Association (AMA), 2010). In the
United States, it is estimated that in any given week, most adults aged
18 years and older take at least one prescription medication, OTC drug,
vitamin, mineral, herbal product or supplement, while 10 percent take
five or more. Overall, 26 percent of the population takes herbal products
and supplements, and 30 percent of prescription drug users take an
herbal product or supplement. In all settings of care, drug-drug
interactions are significant, but undetected causes of ADEs. Drug-drug
interactions—including interactions between drugs a patient is known to
be taking—are frequently not recognized. Controversy, confusion and
uncertainty about the significance of many drug-drug interactions further
increase risk and opportunity for ADEs (AMA, 2010).
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This reporting measure is designed to collect
data needed to score NQF #0419 in the ESRD QIP.
- Numerator statement: For each eligible patient-visit,
facility reports whether or not the patient's list of current
medications is documented.
- Denominator statement: All eligible patient visits.
- Exclusions: Patient is in an urgent or emergent medical
situation where time is of the essence and to delay treatment would
jeopardize the patient’s health status.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: CROWNWeb
- Measure type: Structure
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of workgroup deliberations: Consensus not reached.
Split between conditional support and do not support. MAP considered both
the outcome and reporting version of this measure, noting the reporting
version serves as an important first step towards implementing the
outcome measure. MAP recognized the importance of medication
documentation but raised concerns about the feasibility of this measure.
MAP members noted that most prescriptions are written outside of the
dialysis facility and it can be challenging for providers to determine
what medications a patient is taking. Some members also expressed
concerns that this is a check box metric that will not improve medication
reconciliation. However, other members noted that this measure addresses
a critical program objective that the measure set should expand beyond
dialysis procedures to include cross-cutting aspects of care, including
medication reconciliation. It also addresses the NQS priority of
safety and is included in the MAP duals family.
Public comments received: 7
Preliminary Analysis of Measure
- Preliminary analysis result: Conditional support
- Preliminary analysis summary: Conditional support pending
NQF endorsement. Measure addresses a critical program objective to
expand the measure set beyond dialysis procedures to include non
clinical aspects of care, including medication reconciliation.
Addresses the gap area and NQS priority of safety(inappropriate
medication use) and effective communication and coordination
ofcare.This reporting measure is designed to collect data needed to
score NQF #0419 in the ESRD QIP.
- Does the measure address a critical program objective as
defined by MAP? Yes. Meets a critical program objective
previously identified by MAP to expand the measure set beyond
dialysis procedures to include non clinical aspects of care,
including medication reconciliation.It is estimated that the rate of
adverse drug events in am
- 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 record found. This
reporting measure is designed to collect data needed to score NQF
#0419 in the ESRD QIP.
- Does the measure promote alignment and parsimony? Yes.
Addresses a critical program objective previously identified by MAP
that this measure set should expand beyond dialysis procedures
to include non clinical aspects of care, including medication
reconciliation. Addresses the gap area and NQS priority of
sa
- 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 2005, the rate of
medication errors during hospitalization was estimated to be 52 per 100
admissions, or 70 per 1,000 patient days. Emerging research suggests the
scope of medication-related errors in ambulatory settings is as or more
extensive than during hospitalization. Ambulatory visits result in a
prescription for medication 50 to 70% of the time. One study estimated
the rate of adverse drug events (ADE) in the ambulatory setting to be 27
per 100 patients. It is estimated that between 2004 and 2005, in the
United States 701,547 patients were treated for ADEs in emergency
departments and 117,318 patients were hospitalized for injuries caused by
an ADE. Individuals aged 65 years and older are more likely than
any other population group to require treatment in the emergency
department for ADEs (American Medical Association (AMA), 2010). In the
United States, it is estimated that in any given week, most adults aged
18 years and older take at least one prescription medication, OTC drug,
vitamin, mineral, herbal product or supplement, while 10 percent take
five or more. Overall, 26 percent of the population takes herbal products
and supplements, and 30 percent of prescription drug users take an
herbal product or supplement. In all settings of care, drug-drug
interactions are significant, but undetected causes of ADEs. Drug-drug
interactions—including interactions between drugs a patient is known to
be taking—are frequently not recognized. Controversy, confusion and
uncertainty about the significance of many drug-drug interactions further
increase risk and opportunity for ADEs (AMA, 2010).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP agrees that Physician feedback of
the QRURs will provide more experience with the measure before
deciding whether it can be used for payment. Quality measures are
needed to match this cost measure.
- Public comments received: 4
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP agrees that Physician feedback of
QRURs will provide more information on how this measure works.
Quality measures are needed for GI hemorrhage to match with the cost
measure.
- Public comments received: 2
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a hip replacement surgery is very clearly
defined. Though surgery measures are finalized in PQRS, additional
quality measures specific to hip replacement are needed to match this
cost measure.
- Public comments received: 3
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supported this measures for the
Physician Feedback/QRUR program to continue to understand how the
information can be used to improve performance. Quality measures are
needed to match this cost measure.
- Public comments received: 6
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a knee replacement surgery is very clearly
defined and be matched with 3 finalized measures for knee replacement
in PQRS. Conditional on submission to NQF for
endorsement.
- Public comments received: 3
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a spine surgery is very clearly defined. MAP is
pleased to learn that a quality measure being developed for spine
surgery to match this cost measure.
- Public comments received: 4
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)).
Measure Specifications
- NQF Number (if applicable):
- Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to
avoid bladder and urethral trauma, keeping the urine collection bag
below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI
monitoring, leads to improved patient outcomes and provides a
mechanism for identifying improvements and quality efforts.
- Numerator statement: Total number of observed
healthcare-associated CAUTI among patients in bedded inpatient care
locations (excluding patients in Level II or III neonatal
ICUs).
- Denominator statement: S.7. Denominator Statement: Total
number of indwelling urinary catheter days for each location under
surveillance for CAUTI during the data period. S.10. Denominator
Exclusions: The following are not considered indwelling catheters by
NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In
and out” catheterizations 4. Nephrostomy tubes Note, that if a
patient has either a nephrostomy tube or a suprapubic catheter and
also has an indwelling urinary catheter, the indwelling urinary
catheter will be included in the CAUTI surveillance.
- Exclusions: The following are not considered indwelling
catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom
catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note,
that if a patient has either a nephrostomy tube or a suprapubic
catheter and also has an indwelling urinary catheter, the indwelling
urinary catheter will be included in the CAUTI
surveillance.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported the implementation of
an updated version of this measure currently in the HAC Reduction
Program. This update was recently reviewed and recommended by the NQF
Safety Standing Committee. Implementing this updated measure would
extend the measure to hospital settings outside the ICU and add
another risk adjustment methodology. The two risk adjustment
methodologies are: Standardized Infection Ratio (SIR) uses a
stratification approach to compare CAUTIs incidence rates. For
example, the stratification can be by the hospital’s patient care
location as the predicted number of CAUTIs in a medical ICU may be
different then a general medical/surgical unit. Adjusted
Ranking Metric (ARM) uses a more complex Bayesian estimation
technique to account for the small sample sizes that may be present
in the strata described in the SIR above. To adjust for this
potentially low precision and/or reliability due to sample size, a
statistical adjustment is made to the numerator. While the group was
supportive they noted caution that the measure should be publically
report prior to use in a payment or penalty program to allow for some
experience in the measure for CMS and providers. Expanding the
measure from the ICU to other locations in the hospital significantly
adjusts the measure and experience is needed. MAP also acknowledged
concerns raised by providers specializing in the treatment of
spinal cord injuries and encouraged further consideration on the
trade-offs of including these patients in this measure population.
Finally, several MAP members noted that the ARM calculation is very
difficult to replicate without coefficients from CDC and urged CDC
and CMS to make all elements of the calculation
transparent.
- Public comments received: 9
Rationale for measure provided by HHS
Measure has been
revised and now in NQF re-endorsement process. CAUTI can be minimized by
a collection of prevention efforts. These include reducing the number of
unnecessary indwelling catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters to the patient´s leg
to avoid bladder and urethral trauma, keeping the urine collection
bag below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this measure
to track CAUTIs through a nationalized standard for HAI monitoring, leads
to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another
risk adjustment methodology besides the Standardized Infection Ratio. The
two risk adjustment methodologies are: 1. Standardized Infection Ratio
(annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any
number of stratified groups of data. CAUTI incidence rates stratified by
patient care location type and in some instances, location bed size
and type of medical school affiliation which form the basis of the
population standardization. Example: predicted numbers of CAUTI (and
CAUTI rates) in a medical ICU are not the same as in an SICU. See also
Scientific Validity section for further information on risk adjustment
and variables. 2. Adjusted Ranking Metric (annual aggregation) The
adjusted ranking metric (ARM) combines the method of indirect
standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in
the unadjusted SIR mentioned above. A Bayesian posterior
distribution constructed through Monte Carlo Markov Chain sampling is
used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable):
- Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of
lines are recommended. These efforts result in decreased morbidity
and mortality and reduced healthcare costs.
- Numerator statement: Total number of observed
healthcare-associated CLABSI among patients in bedded inpatient care
locations.
- Denominator statement: S.7. Denominator Statement: Total
number of central line days for each location under surveillance for
CLABSI during the data period. S.10. Denominator Exclusions: 1.
Pacemaker wires and other non-lumened devices inserted into central
blood vessels or the heart are excluded as CLs. 2. Extracorporeal
membrane oxygenation lines, femoral arterial catheters, intraaortic
balloon pump devices, and hemodialysis reliable outflow
catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines
are excluded as CLs.
- Exclusions: Pacemaker wires and other non-lumened devices
inserted into central blood vessels or the heart are excluded as CLs.
2. Extracorporeal membrane oxygenation lines, femoral arterial
catheters, intraaortic balloon pump devices, and hemodialysis
reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral
intravenous lines are excluded as CLs.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP was supportive of the
implementation of an updated version of a measure currently in the
HAC Reduction Program. This update was recently reviewed and
recommended by the NQF Safety Standing Committee. Implementing this
updated measure would extend the measure to hospital settings outside
the ICU and add another risk adjustment methodology. The two risk
adjustment methodologies are: Standardized Infection Ratio (SIR) uses
a stratification approach to compare CLABSI incidence rates. For
example, the stratification can be by the hospital’s patient care
location as the predicted number of CLABSIs in a medical ICU may be
different then a NICU. Adjusted Ranking Metric (ARM) uses a
more complex Bayesian estimation technique to account for the small
sample sizes that may be present in the strata described in the SIR
above. To adjust for this potentially low precision and/or
reliability due to sample size, a statistical adjustment is made to
the numerator. MAP noted that expanding the measure from the ICU to
other locations in the hospital significantly adjusts the measure and
measure use experience is needed.
- Public comments received: 1
Rationale for measure provided by HHS
Updated version of a
current measure in IQR, HVBP, and HACRP CLABSI can be minimized through
proper management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs. Use of this measure to track
CLABSIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and evaluating prevention efforts. Additionally, CDC has
added another risk adjustment methodology besides the Standardized
Infection Ratio. The two risk adjustment methodologies are: 1.
Standardized Infection Ratio (annual and quarter aggregation) The SIR is
constructed by using an indirect standardization method for summarizing
HAI experience across any number of stratified groups of data.
CLABSI incidence rates stratified by patient care location type and in
some instances, location bed size and type of medical school affiliation
which form the basis of the population standardization. Example:
predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the
method of indirect standardization with a Bayesian random effects
hierarchical model to account for the potentially low precision and/or
reliability inherent in the unadjusted SIR mentioned above. A Bayesian
posterior distribution constructed through Monte Carlo Markov Chain
sampling is used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: Percentage of home health episodes of care in
which the patient is discharged from home health with one or more
pressure ulcer(s) that are Stage 2 - 4 or unstageable due to slough
or eschar and are new or worsened since the start or resumption of
care. The measure is based on data obtained from the Outcome
Assessment and Information Set (OASIS-C1) Data Item Set.
- Numerator statement: Number of home health episodes of
care in which the patient is discharged from home health with one or
more pressure ulcer(s) that are Stage 2 - 4 or unstageable due to
slough or eschar and are new or have worsened since the start or
resumption of care.
- Denominator statement: Number of home health episodes of
care ending with a discharge during the reporting period, other than
those covered by generic or measure-specific exclusions.
- Exclusions: Episodes of care ending with a transfer to an
inpatient setting or death are excluded from the denominator. HHA's
with denominator counts of less than 20 in the sample will be
excluded from public reporting owing to small sample
size.
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: OASIS-C1
- Measure type: Intermediate Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending further
development and NQF endorsement. This measure addresses a PAC/LTC
core concept and will be a required measurement domain under the
IMPACT Act. This measure promotes alignment as is harmonized with
NQF# 0678 - "Percent of Residents or Patients with Pressure Ulcers
that are New or Worsened (Short-Stay)" which is used in the SNF, LTCH
and IRF settings. MAP members did suggest the measure include an
exclusion for hospice patients who have ulcers that are unlikely
to heal. Other members also noted that measurement efforts should
focus on the consequences of not detecting a pressure ulcer rather
than the number of patients that might develop one. Some MAP members
raised concerns that this measure might be trying to modify the
behavior of caregivers other than employees of the home health
agency.
- Public comments received: 8
Rationale for measure provided by HHS
Studies have
demonstrated that while pressure ulcers may be relatively rare in the
home health setting, they have a substantial adverse impact on patient
quality of life, and incidence is associated with an increased morbidity
and mortality. They are a national focus because they are widely
seen as preventable with sufficient risk assessment and quality care
provision. This measure is envisioned to encourage agencies to implement
actions that can reduce the development of new pressure ulcers and
facilitate healing to prevent the worsening of existing pressure ulcers.
Additionally, the measure will provide home health agencies and consumers
with information that will enable them to monitor the quality of care
received by all patients at risk of developing pressure ulcers.
Measure Specifications
- NQF Number (if applicable): 0506
- Description: The measure estimates a hospital-level
risk-standardized readmission rate (RSRR) for patients discharged
from the hospital with a principal diagnosis of pneumonia. The
outcome is defined as unplanned readmission for any cause within 30
days of the discharge date for the index admission. A specified set
of planned readmissions do not count as readmissions. The target
population is patients 18 and over. CMS annually reports the measure
for patients who are 65 years or older and are either enrolled in
fee-for-service (FFS) Medicare and hospitalized in non-federal
hospitals or are hospitalized in Veterans Health Administration (VA)
facilities.
- Numerator statement: The outcome for this measure is
30-day readmission. We define readmission as an inpatient admission
for any cause, with the exception of certain planned readmissions,
within 30 days from the date of discharge from the index pneumonia
admission. If a patient has more than one unplanned admission within
30 days of discharge from the index admission, only the first one is
counted as a readmission. The measure looks for a dichotomous yes or
no outcome of whether each admitted patient has an unplanned
readmission within 30 days. However, if the first readmission after
discharge is considered planned, any subsequent unplanned readmission
is not counted as an outcome for that index admission because the
unplanned readmission could be related to care provided during
the intervening planned readmission rather than during the index
admission.
- Denominator statement: The denominator includes patients
18 and over hospitalized for pneumonia. The measure is currently
publicly reported by CMS for those 65 years and older who are either
Medicare FFS beneficiaries admitted to non-federal hospitals or
patients admitted to VA hospitals. In 2014, we propose updating our
current definition of pneumonia to include patients with a principal
discharge diagnosis of aspiration pneumonia (defined by ICD-9-CM Code
507.0) and patients with a principal discharge diagnosis of sepsis
(defined by ICD-9-CM codes 995.91, 995.92, 038, 038.0, 038.1,
038.10, 038.11, 038.12, 038.19, 038.2,038.3, 038.4, 038.40, 038.41,
038.42, 038.43, 038.44, 038.49, 038.8, 038.9, and 785.52) or
respiratory failure (defined by ICD-9-CM codes 518.81, 518.82.
518.84, and 799.1) and a secondary diagnosis of pneumonia coded as
present on admission (POA). To be included in the measure cohort used
in public reporting, patients must meet the following additional
inclusion criteria: enrolled in Part A and Part B Medicare for the 12
months prior to the date of admission, and enrolled in Part A
during the index admission (this criterion does not apply to
patients discharged from VA hospitals); not transferred to another
acute care facility; and alive at discharge.[For reference,
denominator for NQF endorsed measure in QPS: The target population
for this measure is patients aged 18 years and older discharged from
the hospital with a principal diagnosis of pneumonia with a complete
claims history for the 12 months prior to admission. The measure is
currently publicly reported by CMS for those 65 years and older who
are either Medicare FFS beneficiaries admitted to non-federal
hospitals or patients admitted to VA hospitals.As noted above, this
measure can also be used for an all-payer population aged 18 years
and older. We have explicitly tested the measure in both patients
aged 18+ years and those aged 65+ years.]
- Exclusions: For all cohorts, the measure excludes
admissions for patients: -Discharged against medical advice (AMA);
-Admitted with pneumonia within 30 days of discharge from a
qualifying index admission (Admissions within 30 days of discharge of
an index admission will be considered readmissions. No admission is
counted as a readmission and an index admission. The next eligible
admission after the 30-day time period following an index admission
will be considered another index admission.) For Medicare FFS
patients, the measure additionally excludes admissions for patients:
-Without at least 30 days post-discharge enrollment in FFS
Medicare
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported a revised version of
the measure that would expand the cohort of patients included in the
measure to include patients with a primary diagnosis of aspiration
pneumonia for use in HRRP. While MAP members agreed that this is a
high-impact outcome measure, part of the MAP Safety Family of
Measures, and in use in several public and private programs, they did
express caution. The MAP noted that this measure should be considered
for SDS adjustment in the upcoming NQF trial period, reviewed for the
empirical and conceptual relationship between SDS factors and
pneumonia readmissions, and endorsed with appropriate SDS adjustment
as determined by NQF standing committees. MAP also cautioned that CMS
carefully implement updated versions of measures to minimize
confusion among providers, consumers, and purchasers trying to
understand the results of the measure and make decisions based off of
these results.
- Public comments received: 3
Rationale for measure provided by HHS
The Medicare Payment
Advisory Commission (MedPAC) has called for hospital-specific public
reporting of readmission rates, identifying pneumonia as a priority
condition (MedPAC, 2007). MedPAC finds that readmissions are common,
costly, and often preventable. Based on 2005 Medicare data, MedPAC
estimates that about 8.9% of Medicare pneumonia admissions were followed
by a readmission within 15 days, accounting for more than 74,000
admissions at a cost of $533 million. Pneumonia results in approximately
1.2 million hospital admissions each year and accounts for more than $10
billion annually in hospital expenditures. Among patients over 65 years
of age, it is the second leading cause of hospitalization, and is the
leading infectious cause of death (Lindenauer et. al., 2011).
Approximately 20% of pneumonia patients were rehospitalized within thirty
days, representing the second-highest proportion of all
rehospitalizations at 6.3% (Jencks 2009). Pneumonia readmission is a
costly event and represents an undesirable outcome of care from the
patient’s perspective, and highly disparate pneumonia readmission rates
among hospitals suggest there is room for improvement. (MedPAC 2007,
Bernheim 2010). References: Bernheim SM, et al. 2010 Measures Maintenance
Technical Report: Acute Myocardial Infarction, Heart Failure and
Pneumonia 30-day Risk Standardized Mortality Rate. 2010 Available at:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier3&cid=1163010421830
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among
patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr
2;360(14):1418-28. Lindenauer PK, Normand SL, Drye EE, et al.
Development, validation, and results of a measure of 30-day readmission
following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
Report to the Congress: Promoting Greater Efficiency in Medicare.
Washington, DC: Medicare Payment Advisory Commission, 2007.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: Hospital-specific, risk-standardized, 30-day
episode of care payment for AMI. The measure includes all payments
across care settings for the 30-days following an inpatient admission
for AMI. The payments are either "stripped” or “standardized" to
remove the effect of policy adjustments. The measure uses
hierarchical modelling to estimate hospital-level risk-standardized
total payments for the 30-day window from admission.
- Numerator statement: The outcome for this measure is
Medicare payments for an AMI episode of care. The payment timeframe
is defined as admission for an index hospitalization through 30 days
post-admission. We include payments for inpatient settings and up to
6 other post-discharge settings (Skilled Nursing Facility,
Outpatient, Home Health Agency, Hospice, Carrier, and Durable Medical
Equipment).
- Denominator statement: The target population for this
measure includes episodes of care (as defined above) for patients who
are 65 years of age or older with a principal discharge diagnosis of
AMI (as defined by ICD-9 codes 410.xx, excluding 410.x2) during a
qualifying index hospitalization.
- Exclusions: Lack of continuous enrollment in Medicare FFS
Parts A and B in the 12 months prior to index hospital stay. 2) Lack
of continuous enrollment in Medicare FFS Parts A and B in the month
following the index hospital stay (if alive). 3) Patients discharged
alive on the day of admission who did not get transferred. 4)
Transfers into the hospital (excluded from eligibility as an index
admission), or transfers to federal hospitals. 5) Patients who are
discharged against medical advice (AMA). 6) Occurred in Maryland
hospitals and U.S. territories. 7)Episodes for Patients with 0
Payment
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims
- Measure type: Cost/ Resource Use
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
Rationale for measure provided by HHS
This is a high
priority (per episode) resource use measure. AMI is a condition with a
substantial range in costs of care and for which there are
well-established publicly reported quality measures; therefore, it is an
ideal condition for assessing relative value for an episode of care that
begins with an acute hospitalization. Moreover, AMI is one of the leading
cause of hospitalization for Americans over 65 years old and costs the US
roughly $18 billion annually. Medicare payments are difficult to
interpret in isolation. Some high payment hospitals may have better
clinical outcomes when compared with low payment hospitals; other high
payment hospitals may not. For this reason, the value of hospital care is
more clearly assessed when pairing hospital payments with hospital
quality. A measure of payments for Medicare patients during an episode of
care for AMI aligned with current quality of care measures will
facilitate profiling hospital value (payments and quality). This measure,
which uses standardized payments, reflects differences in the
management of care for patients with AMI both during hospitalization and
immediately post-discharge. By focusing on one specific condition, value
assessments may provide actionable feedback to hospitals and incentivize
targeted improvements in care. This measure is harmonized with NQF E0230.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
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)).
Measure Specifications
- NQF Number (if applicable): 0351
- Description: Percentage of cases having developed
specified complications of care with an in-hospital death.
- Numerator statement: All discharges with a disposition of
“deceased” (DISP=20) among cases meeting the inclusion and exclusion
rules for the denominator.
- Denominator statement: All surgical discharges age 18
years and older or MDC 14 (pregnancy, childbirth, and puerperium)
defined by specific DRGs or MS-DRGs and an ICD-9-CM code for an
operating room procedure, principal procedure within 2 days of
admission OR admission type of elective (ATYPE=3) with potential
complications of care listed in Death among Surgical definition
(e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI
hemorrhage/acute ulcer).
- Exclusions: Exclude cases: • age 90 years and older •
transferred to an acute care facility (DISP = 2) • missing discharge
disposition (DISP=missing), gender (SEX=missing), age (AGE=missing),
quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis
(DX1 =missing)
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Agency for Healthcare Research & Quality
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending a review by the relevant NQF Standing Committee of
the reliability and validity testing of this measure for the Medicare
fee-for-service population. While the MAP agreed that this measure
addresses a number of important and improvable patient safety
concerns, several members of the Committee noted concerns with the
low level of reliability for this AHRQ PSI in the Medicare FFS
population. Given the conflicting data presented to MAP, the group
agreed that the relevant NQF Standing Committee should review this
analysis. Given that this measure is proposed for use in a pay for
performance program, MAP agreed that the testing of this
measure in the population for which it will be used need to be should
be sufficiently robust.
- Public comments received: 4
Rationale for measure provided by HHS
Silber and colleagues
have published a series of studies establishing the construct validity of
failure to rescue rates through their associations with hospital
characteristics and other measures of hospital performance. Among
patients admitted for cholecystectomy and transurethral prostatectomy,
failure to rescue was independent of severity of illness at admission,
but was significantly associated with the presence of surgical
housestaff and a lower percentage of board-certified anesthesiologists.31
The adverse occurrence rate was independent of this hospital
characteristic. In a larger sample of 74,647 patients who underwent
general surgical procedures in 1991-92, lower failure to rescue rates
were found at hospitals with high ratios of registered nurses to beds.68
Failure rates were strongly associated with risk adjusted mortality
rates, as expected, but not with complication rates.143 Finally, among
16,673 patients admitted for coronary artery bypass surgery, failure
rates were lower (whereas complication rates were higher) at hospitals
with magnetic resonance imaging facilities, bone marrow transplantation
units, or approved residency training programs. More recently, Needleman
and Buerhaus, confirmed that higher registered nurse staffing (RN
hours/adjusted patient day) and better nursing skill mix (RN
hours/licensed nurse hours) were consistently associated with lower
failure to rescue rates among major surgery patients from 799 hospitals
in 11 states in 1997, even using administrative data to define
complications. An increase from the 25th to the 75th percentile on these
two measures of staffing was associated with 5.9% (95% CI, 1.5% to 10.2%)
and 3.9% (95% CI, -1.1% to 8.8%) decreases, respectively, in the rate of
failure-to-rescue among major surgery patients.138 These associations
were inconsistent among medical patients, in that nursing skill mix
was associated with the failure-to-rescue rate (rate ratio 0.81, 95% CI
0.66-1.00) but aggregate registered nurse staffing was not (rate ratio
1.00, 95% CI 0.99-1.01). An increase from the 25th to the 75th percentile
on nursing skill mix was associated with a 2.5% (95% CI, 0.0% to 5.0%)
decrease in the failure-to-rescue rate among medical patients.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 1
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)).
Measure Specifications
- NQF Number (if applicable): 1893
- Description: The measure estimates a hospital-level
risk-standardized mortality rate (RSMR), defined as death from any
cause within 30 days after the index admission date, for patients 40
and older discharged from the hospital with either a principal
diagnosis of COPD or a principal diagnosis of respiratory failure
with a secondary diagnosis of acute exacerbation of COPD. CMS will
annually report the measure for patients who are 65 years or older,
enrolled in fee-for-service (FFS) Medicare, and hospitalized in
non-federal hospitals.
- Numerator statement: The outcome for this measure is
30-day all-cause mortality. We define mortality as death from any
cause within 30 days from the date of admission for patients 40 and
older discharged from the hospital with either a principal diagnosis
of COPD or a principal diagnosis of respiratory failure with a
secondary diagnosis of acute exacerbation of COPD.
- Denominator statement: This claims-based measure can be
used in either of two patient cohorts: (1) patients aged 65 years or
older or (2) patients aged 40 years or older. The cohort includes
admissions for patients discharged from the hospital with either a
principal diagnosis of COPD OR a principal diagnosis of respiratory
failure WITH a secondary diagnosis of acute exacerbation of COPD and
with a complete claims history for the 12 months prior to
admission.
- Exclusions: The measure excludes index admissions for
patients: 1. Discharged alive on the day of admission or the
following day who were not transferred; 2. With inconsistent or
unknown vital status or other unreliable demographic data; 3.
Enrolled in the Medicare hospice program any time in the 12 months
prior to the index admission, including the first day of the index
admission; and 4. Who were discharged against medical advice
(AMA).[For reference, additional exclusion text for endorsed measure
in QPS:After the above exclusions (#1-4) are applied, the measure
randomly selects one index admission per patient per year for
inclusion in the cohort. Each episode of care must be mutually
independent with the same probability of the outcome. The probability
of death increases with each subsequent admission and therefore the
episodes of care are not mutually independent. For the three year
combined data, when index admissions occur during the transition
between measure reporting periods (June and July of each year) and
both are randomly selected for inclusion in the measure, the
measure only includes the June admission. The July admissions are
excluded from the measure to avoid assigning a single death to two
admissions.]
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: The MAP supported this measure for
inclusion in the VBP program. The group agreed that the program
currently includes 30 day mortality rates for AMI, heart failure, and
pneumonia, thus including 30 day mortality rates for COPD would be
appropriate. This measure is currently used in the IQR program thus
supporting alignment and parsimony. Members of the workgroup
reiterated that is important that measures in this program are
publically reported for one year prior to use in payment applications
to gain additional experience with the measure.
- Public comments received: 3
Rationale for measure provided by HHS
The prevalence of
heart failure (HF) in the United States (U.S.) is high, with 5.2 million
Americans currently diagnosed with this condition (Rosamond et al.,
2007). HF incidence increases with age and approaches 10 per 1000
population after age 65 (Rosamond et al., 2007). HF is one of the most
common causes for hospital admissions among Medicare beneficiaries
(Merrill and Elixhauser, 2005) and hospital discharges for HF increased
175% from 1979 to 2004 (Rosamond et al., 2007). A recent study
reported that more than 2.5 million Medicare Fee-for-Service (FFS)
beneficiaries were hospitalized for HF during 2001-2005, and more than 1
in 10 Medicare beneficiaries died within 30 days of hospitalization
(Curtis et al., 2008). Thirty-day HF mortality rates vary considerably
across hospitals (Rosenthal et al., 2000) and hospitals that perform well
on the Hospital Quality Alliance (HQA) performance measures have lower
risk-adjusted mortality rates (Jha et al., 2007). The high prevalence
and considerable morbidity and mortality associated with HF create an
economic burden on the healthcare system. In 2005, HF was the fifth most
expensive condition treated in U.S. hospitals, accounting for 3.5% of the
national hospital bill. It was also the second most expensive condition
billed to Medicare that year, accounting for 5.5% of Medicare's hospital
bill (Andrews and Elixhauser, 2007). Many current hospital
interventions are known to decrease the risk of death within 30 days of
hospital admission. Current process-based performance measures, however,
cannot capture all the ways that care within the hospital might influence
outcomes. As a result, many stakeholders, including patient
organizations, are interested in outcomes measures that would permit
groups of providers to assess their relative outcomes performance for the
purpose of internal quality improvement or public reporting. Mortality of
patients with HF represents a significant outcome potentially
related to quality of care. This rate-based indicator identifies an
undesirable outcome of care. High rates warrant investigation into the
quality of care provided.
Measure Specifications
- NQF Number (if applicable): 0468
- Description: The measure estimates a hospital 30-day
risk-standardized mortality rate (RSMR), defined as death for any
cause within 30 days after the date of admission of the index
admission, for patients 18 and older discharged from the hospital
with a principal diagnosis of pneumonia. CMS annually reports the
measure for patients who are 65 years or older and are either
enrolled in fee-for-service (FFS) Medicare and hospitalized in
non-federal hospitals or are hospitalized in Veterans Health
Administration (VA) facilities.
- Numerator statement: The outcome for this measure is
30-day all-cause mortality. We define mortality as death from any
cause within 30 days of the index admission date for patients 18 and
older discharged from the hospital with a principal diagnosis of
pneumonia.[For reference, additional text on numerator included for
endorsed measure on QPS: The numerator of the risk-adjusted ratio is
the predicted number of deaths within 30 days given the hospital’s
performance with its observed case mix. The term “predicted”
describes the numerator result, which is calculated using the
hospital-specific intercept term. (See details below in the 2a1.13
Statistical risk model and variables.)]
- Denominator statement: The denominator includes patients
aged 18 and over admitted to an acute care hospital for pneumonia and
with a complete claims history for the 12 months prior to admission.
The measure is currently publicly reported by CMS for those 65 years
and older who are either Medicare FFS beneficiaries admitted to
non-federal hospitals or patients admitted to VA hospitals. In 2014,
we propose updating our current definition of pneumonia to include
patients with a principal discharge diagnosis of aspiration
pneumonia (defined by ICD-9-CM Code 507.0) and patients with a
principal discharge diagnosis of sepsis (defined by ICD-9-CM codes
995.91, 995.92, 038, 038.0, 038.1, 038.10, 038.11, 038.12, 038.19,
038.2,038.3, 038.4, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49,
038.8, 038.9, and 785.52) or respiratory failure (defined by ICD-9-CM
codes 518.81, 518.82. 518.84, and 799.1) and a secondary diagnosis of
pneumonia coded as present on admission (POA). Patients who are
transferred from one acute care facility to another must have a
principal discharge diagnosis of pneumonia at both hospitals. The
initial hospital for a transferred patient is designated as the
responsible institution for the episode.[For reference, denominator
for NQF endorsed measure on QPS: This claims-based measure can be
used in either of two patient cohorts: (1) patients aged 65 years or
older or (2) patients aged 18 years or older.The cohort includes
admissions for patients discharged from the hospital with a principal
discharge diagnosis of pneumonia and with a complete claims
history for the 12 months prior to admission.]
- Exclusions: The measure excludes index admissions for
patients: 1. Discharged alive on the day of admission or the
following day who were not transferred; 2. With inconsistent or
unknown vital status or other unreliable demographic data; 3.
Enrolled in the Medicare hospice program or VA hospice services any
time in the 12 months prior to the index admission, including the
first day of the index admission; and 4. Who were discharged against
medical advice (AMA). After the above exclusions (#1-4) are applied,
the measure randomly selects one index admission per patient per year
for inclusion in the cohort. Each episode of care must be mutually
independent with the same probability of the outcome. The
probability of death increases with each subsequent admission and
therefore the episodes of care are not mutually independent. For the
three year combined data, when index admissions occur during the
transition between measure reporting periods (June and July of each
year) and both are randomly selected for inclusion in the measure,
the measure only includes the June admission. The July admissions are
excluded from the measure to avoid assigning a single death to
two admissions.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending NQF review of the updates to this measure and
continued endorsement. MAP reviewed a revised version of this measure
that would expand the cohort of patients included in the measure to
include patients with a primary diagnosis of aspiration pneumonia and
sepsis. The MAP noted that pneumonia mortality remains an important
area of hospital quality and this expanded measure could potentially
reduce coding biases. This high-impact fully specified, tested and
endorsed outcome measure is already in use in several public and
private programs including IQR.
- Public comments received: 2
Rationale for measure provided by HHS
Among patients over
65 years of age, pneumonia is the second leading cause of
hospitalization, and is the leading infectious cause of death (Lindenauer
et al., 2011). Many current hospital interventions are known to decrease
the risk of death within 30 days of hospital admission (Jha et. al.,
2007). Current process-based performance measures, however, cannot
capture all the ways that care within the hospital might influence
outcomes. As a result, many stakeholders, including patient
organizations, are interested in outcomes measures that allow patients
and providers to assess relative outcomes performance for hospitals
(Bratzler et al., 2007). References: Bratzler, DW, Nsa W, Houck PM.
Performance measures for pneumonia: are they valuable, and are process
measures adequate. Current Opinion in Infectious Diseases. 20(2):182-189,
April 2007. Jha AK, Orav EJ, Li Z, Epstein AM. The inverse relationship
between mortality rates and performance in the Hospital Quality Alliance
measures. Health Aff (Millwood) 2007 Jul-Aug;26(4):1104-10. Lindenauer
PK, Normand SL, Drye EE, et al. Development, validation, and results
of a measure of 30-day readmission following hospitalization for
pneumonia. J Hosp Med. 2011;6(3):142-150
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 2
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 1
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)).
Measure Specifications
- NQF Number (if applicable):
- Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to
avoid bladder and urethral trauma, keeping the urine collection bag
below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI
monitoring, leads to improved patient outcomes and provides a
mechanism for identifying improvements and quality efforts.
- Numerator statement: Total number of observed
healthcare-associated CAUTI among patients in bedded inpatient care
locations (excluding patients in Level II or III neonatal
ICUs).
- Denominator statement: S.7. Denominator Statement: Total
number of indwelling urinary catheter days for each location under
surveillance for CAUTI during the data period. S.10. Denominator
Exclusions: The following are not considered indwelling catheters by
NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In
and out” catheterizations 4. Nephrostomy tubes Note, that if a
patient has either a nephrostomy tube or a suprapubic catheter and
also has an indwelling urinary catheter, the indwelling urinary
catheter will be included in the CAUTI surveillance.
- Exclusions: The following are not considered indwelling
catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom
catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note,
that if a patient has either a nephrostomy tube or a suprapubic
catheter and also has an indwelling urinary catheter, the indwelling
urinary catheter will be included in the CAUTI
surveillance.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported the
implementation of an updated version of a measure currently in the
VBP program but noted caution that the measure should be publically
reported prior to use in a payment or penalty program to allow for
some experience in the measure for CMS and providers. This update was
recently reviewed and recommended by the NQF Safety Standing
Committee. Implementing this updated measure would extend the measure
to hospital settings outside the ICU and add another risk adjustment
methodology. The two risk adjustment methodologies are:
Standardized Infection Ratio (SIR) uses a stratification approach to
compare CAUTIs incidence rates. For example, the stratification can
be by the hospital’s patient care location as the predicted number of
CAUTIs in a medical ICU may be different then a general
medical/surgical unit. Adjusted Ranking Metric (ARM) uses a more
complex Bayesian estimation technique to account for the small sample
sizes that may be present in the strata described in the SIR above.
To adjust for this potentially low precision and/or reliability due
to sample size, a statistical adjustment is made to the
numerator. Expanding the measure from the ICU to other locations in
the hospital significantly adjusts the measure and experience is
needed. The MAP also acknowledged concerns raised by providers
specializing in the treatment of spinal cord injuries and encouraged
further consideration on the trade-offs of including these patients
in this measure population. Finally, several MAP members noted that
the ARM calculation is very difficult to replicate without
coefficients from CDC and urged CDC and CMS to make all elements of
the calculation transparent. MAP also cautioned that CMS should take
steps to minimize confusion when implementing updates to measures
currently being used.
- Public comments received: 7
Rationale for measure provided by HHS
Measure has been
revised and now in NQF re-endorsement process. CAUTI can be minimized by
a collection of prevention efforts. These include reducing the number of
unnecessary indwelling catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters to the patient´s leg
to avoid bladder and urethral trauma, keeping the urine collection
bag below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this measure
to track CAUTIs through a nationalized standard for HAI monitoring, leads
to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another
risk adjustment methodology besides the Standardized Infection Ratio. The
two risk adjustment methodologies are: 1. Standardized Infection Ratio
(annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any
number of stratified groups of data. CAUTI incidence rates stratified by
patient care location type and in some instances, location bed size
and type of medical school affiliation which form the basis of the
population standardization. Example: predicted numbers of CAUTI (and
CAUTI rates) in a medical ICU are not the same as in an SICU. See also
Scientific Validity section for further information on risk adjustment
and variables. 2. Adjusted Ranking Metric (annual aggregation) The
adjusted ranking metric (ARM) combines the method of indirect
standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in
the unadjusted SIR mentioned above. A Bayesian posterior
distribution constructed through Monte Carlo Markov Chain sampling is
used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable):
- Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of
lines are recommended. These efforts result in decreased morbidity
and mortality and reduced healthcare costs.
- Numerator statement: Total number of observed
healthcare-associated CLABSI among patients in bedded inpatient care
locations.
- Denominator statement: S.7. Denominator Statement: Total
number of central line days for each location under surveillance for
CLABSI during the data period. S.10. Denominator Exclusions: 1.
Pacemaker wires and other non-lumened devices inserted into central
blood vessels or the heart are excluded as CLs. 2. Extracorporeal
membrane oxygenation lines, femoral arterial catheters, intraaortic
balloon pump devices, and hemodialysis reliable outflow
catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines
are excluded as CLs.
- Exclusions: Pacemaker wires and other non-lumened devices
inserted into central blood vessels or the heart are excluded as CLs.
2. Extracorporeal membrane oxygenation lines, femoral arterial
catheters, intraaortic balloon pump devices, and hemodialysis
reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral
intravenous lines are excluded as CLs.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported the
implementation of an updated version of this measure currently in the
VBP Program but they noted caution that the measure should be
publically reported prior to use in a payment or penalty program to
allow for some experience in the measure for CMS and providers. This
update was recently reviewed and recommended by the NQF Safety
Standing Committee. Implementing this updated measure would extend
the measure to hospital settings outside the ICU and add another risk
adjustment methodology. The two risk adjustment methodologies are:
Standardized Infection Ratio (SIR) uses a stratification
approach to compare CLABSI incidence rates. For example, the
stratification can be by the hospital’s patient care location as the
predicted number of CLABSIs in a medical ICU may be different then a
NICU. Adjusted Ranking Metric (ARM) uses a more complex Bayesian
estimation technique to account for the small sample sizes that may
be present in the strata described in the SIR above. To adjust for
this potentially low precision and/or reliability due to sample size,
a statistical adjustment is made to the numerator. MAP noted that
expanding the measure from the ICU to other locations in the hospital
significantly adjusts the measure and measure use experience
is needed. MAP also cautioned that CMS should take steps to minimize
confusion when implementing updates to measures currently being
used.
- Public comments received: 1
Rationale for measure provided by HHS
Updated version of a
current measure in IQR, HVBP, and HACRP CLABSI can be minimized through
proper management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs. Use of this measure to track
CLABSIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and evaluating prevention efforts. Additionally, CDC has
added another risk adjustment methodology besides the Standardized
Infection Ratio. The two risk adjustment methodologies are: 1.
Standardized Infection Ratio (annual and quarter aggregation) The SIR is
constructed by using an indirect standardization method for summarizing
HAI experience across any number of stratified groups of data.
CLABSI incidence rates stratified by patient care location type and in
some instances, location bed size and type of medical school affiliation
which form the basis of the population standardization. Example:
predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the
method of indirect standardization with a Bayesian random effects
hierarchical model to account for the potentially low precision and/or
reliability inherent in the unadjusted SIR mentioned above. A Bayesian
posterior distribution constructed through Monte Carlo Markov Chain
sampling is used to produce the adjusted numerator.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
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)).
Measure Specifications
- NQF Number (if applicable): 1663
- Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age and older to
whom a brief intervention was provided, or offered and refused, and a
second rate, a subset of the first, which includes only those
patients who received a brief intervention. The Provided or Offered
rate (SUB-2), describes patients who screened positive for unhealthy
alcohol use who received or refused a brief intervention during the
hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate
describes only those who received the brief intervention during
the hospital stay. Those who refused are not included.[For reference,
additional description for endorsed measure included in QPS: These
measures are intended to be used as part of a set of 4 linked
measures addressing Substance Use (SUB-1 Alcohol Use Screening ;
SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at
Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after
Discharge).]
- Numerator statement: SUB-2 The number of patients who
received or refused a brief intervention. SUB-2a The number of
patients who received a brief intervention.
- Denominator statement: The number of hospitalized
inpatients 18 years of age and older who screen positive for
unhealthy alcohol use or an alcohol use disorder (alcohol abuse or
alcohol dependence).
- Exclusions: Patients less than 18 years of age • Patient
who are cognitively impaired • Patients who refused or were not
screened for alcohol use during the hospital stay • Patients who
have a duration of stay less than or equal to three days or greater
than 120 days • Patients receiving Comfort Measures Only
documented[For reference, exclusion for endorsed measure in QPS: The
denominator has 4 exclusions as follows:• Patients less than 18 years
of age• Patient who are cognitively impaired• Patients who refused or
were not screened for alcohol use during the hospital stay• Patients
who have a length of stay less than or equal to one day and
greater than 120 days]
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Clinical Data, Paper
Medical Record
- Measure type: Process
- Steward: The Joint Commission
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported this endorsed measure
noting that it fills a gap in person-centered psychiatric care
through the identification and management of general medical
conditions. The measure is fully specified and tested at the facility
level. Several MAP members encouraged CMS to consider either
expanding this measure, or developing new measure concepts that
examine substance abuse beyond alcohol.
- Public comments received: 5
Rationale for measure provided by HHS
Excessive use of
alcohol and drugs has a substantial harmful impact on health and society
in the United States. It is a drain on the economy, and a source of
enormous personal tragedy (The National Quality Forum, A consensus
Report, 2007). In 1998 the economic costs to society were 185 billion
dollars for alcohol misuse and 143 billion dollars for drug misuse
(Harwood 2000). Health care spending was 19 billion dollars for alcohol
problems and 14 billion dollars was spent treating drug problems. Nearly
a quarter of a trillion dollars per year in lost productivity is
attributable to substance use. More than 537,000 die each year as a
consequence of alcohol, drug, and tobacco use, making use of these
substances the cause of one out of four deaths in the United States
(Mokdad 2004). An estimated 22.6 million adolescents and adults meet
criteria for a substance use disorder. In a multi-state study that
screened 459,599 patients in general hospital and medical settings, 23%
of patients screened positive (Madras 2009). Clinical trials have
demonstrated that brief interventions, especially prior to the onset of
addiction, significantly improve health and reduce costs, and that
similar benefits occur in those with addictive disorders who are referred
to treatment (Fleming 2002). In a study on the provision of
evidence-based care and preventive services provided in hospitals for 30
different medical conditions, quality varied substantially according to
diagnosis. Adherence to recommended practices for treatment of substance
use ranked last, with only 10% of patients receiving proper care
(Gentilello 2005). Currently, less than one in twenty patients with an
addiction are referred for treatment (Gentilello 1999). Hospitalization
provides a prime opportunity to address the entire spectrum of substance
use problems within the health care system (Bernstein 2005).
Measure Specifications
- NQF Number (if applicable): 0648
- Description: Percentage of patients, regardless of age,
discharged from an inpatient facility (e.g., hospital inpatient or
observation, skilled nursing facility, or rehabilitation facility) to
home or any other site of care for whom a transition record was
transmitted to the facility or primary physician or other health care
professional designated for follow-up care within 24 hours of
discharge
- Numerator statement: Patients for whom a transition record
was transmitted to the facility or primary physician or other health
care professional designated for follow-up care within 24 hours of
discharge
- Denominator statement: All patients, regardless of age,
discharged from an inpatient facility (e.g., hospital inpatient or
observation, skilled nursing facility, or rehabilitation facility) to
home/self-care or any other site of care
- Exclusions: Patients who died Patients who left against
medical advice (AMA) or discontinued care
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record
- Measure type: Process
- Steward: American Medical Association - Physician
Consortium for Performance Improvement
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP was supportive of this measure
and noted that this fully specified and tested NQF-endorsed process
measure contributes to the efficient use of measurement resources and
addresses a critical program objective and is highly impactful to
patients by improving person-centered by facilitating care
coordination and has the potential to reduce readmission. While the
group was supportive, they did note caution since this measure may be
duplicative of an existing measure, HBIPS-7 Post Discharge
Continuing Care Plan Transmitted to Next Level Care Provider upon
Discharge, which is developed and specified for psychiatric
facilities. Several members of the MAP encouraged a selection of a
best in class measure or a harmonized metric by an appropriate
Standing Committee between this measure and HBIPS-7 for the purposes
for reporting and accreditation. Further, members also noted that
this measure should be specified for use in all acute-care settings
facilities, as appropriate.
- Public comments received: 4
Rationale for measure provided by HHS
This measure is
important to decrease cost, address gaps in care, and enhance
coordination of communication. Cost • In 2006, there were over 39 million
hospital discharges; of those, 13 percent of these patients are
repeatedly hospitalized and use 60 percent of the healthcare resources. •
A 2007 report by the Medicare Payment Advisory Commission estimated
approximately 18 percent of admissions result in readmissions within 30
days, costing CMS $15 billion. Gaps in Care: • Sabogal and colleagues
found that uncoordinated transitions between sites of care, even
within the same institution, and between caregivers increase hospital
readmissions, medical errors, duplication of services, and waste of
resources. • Moore and colleagues examined three types of discontinuity
of care among older patients transferred from the hospital: medication,
test result follow-up, and initiation of a recommended work-up. They
found that nearly 50 percent of hospitalized patients experienced at
least one discontinuity and that patients who did not have a recommended
work-up initiated were six times more likely to be re-hospitalized.
• A prospective, cross-sectional study by Roy and colleagues found that
approximately 40 percent of patients have pending test results at the
time of discharge and that 10 percent of these require some ac Emergency
Department Visits • The 2008 National Health Statistics Report
determined that 2.3 million (2 percent) emergency department visits are
from patients who were discharged from the hospital within the
previous 7 days. The report also cited the following: • Ten percent of
the 2.3 million emergency department visits were for complications
related to their recent hospitalization, and • The uninsured are 3 times
more likely to visit the emergency department. Medication errors: • An
estimated 60 percent of medication errors occur during times of
transition: upon admission, transfer, or discharge of a patient. • During
care transitions, patients receive medications from different
prescribers who rarely have access to patients’ comprehensive medication
list. • Forster and colleagues found that 19 percent of discharged
patients experienced an associated adverse event within three weeks of
leaving the hospital; 66 percent of these were adverse drug events.
Coleman EA, Min S, Chomiak A, Kramer AM. 2004. Post-hospital care
transitions: patterns, complications, and risk identification. Health
Services Research 39:1449–1465. Agency for Healthcare Research and
Quality (ARHQ). 1999. Outcomes by Patient and Hospital Characteristics
for All Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp.
Kramer A, Eilertsen T, Lin M, Hutt E. 2000. Effects of nurse staffing on
hospital transfer quality measures for new admissions. Pp. 9.1–9.22.
Inappropriateness of Minimum Nurse Staffing Ratios for Nursing Homes.
Health Care Financing Administration. Hutt E, Ecord M, Eilertsen TB, et
al. Precipitants of emergency room visits and acute hospitalization
in short-stay Medicare nursing home residents. J Am Geriatr Soc 2001;
50: 223-229. Jack BW, Chetty VK, Anthony D, et al. A reengineered
hospital discharge program to decrease rehospitalization. Ann Intern Med
2009; 150:178-187. Agency for Healthcare Research and Quality (ARHQ).
2006. Outcomes by Patient and Hospital Characteristics for All
Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp. Medicare
Payment Advisory Commission. A data book: Healthcare spending and the
Medicare program. June 2007. Available at:
http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf. Harris
G. Report finds a heavy toll from medication errors, N.Y. Times (July 21,
2006). Available at:
http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=5088&partner=rssnyt&emc=rss.
Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions
interventions: Improving patient safety and healthcare quality. CAHQ
Journal 2007 (Quarter 2). Moore C
Measure Specifications
- NQF Number (if applicable): 1656
- Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age an older to
whom tobacco use treatment was provided, or offered and refused, at
the time of hospital discharge, and a second rate, a subset of the
first, which includes only those patients who received tobacco use
treatment at discharge. Treatment at discharge includes a referral to
outpatient counseling and a prescription for one of the FDA-approved
tobacco cessation medications. TOB-3 Patients identified as
tobacco product users within the past 30 days who were referred to or
refused evidence-based outpatient counseling AND received or refused
a prescription for FDA-approved cessation medication upon discharge.
TOB-3a Patients who were referred to evidence-based outpatient
counseling AND received a prescription for FDA-approved cessation
medication upon discharge as well as those who were referred to
outpatient counseling and had reason for not receiving a prescription
for medication.[For reference, description of endorsed measure in
QPS: The measure is reported as an overall rate which includes
all hospitalized patients 18 years of age an older to whom tobacco
use treatment was provided, or offered and refused, at the time of
hospital discharge, and a second rate, a subset of the first, which
includes only those patients who received tobacco use treatment at
discharge. Treatment at discharge includes a referral to outpatient
counseling and a prescription for one of the FDA-approved tobacco
cessation medications. Refer to section 2a1.10 Stratification
Details/Variables for the rationale for the addition of the subset
measure. These measures are intended to be used as part of a set of 4
linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening;
TOB 2 Tobacco Use Treatment Provided or Offered During the Hospital
Stay; TOB-4 Tobacco Use: Assessing Status After
Discharge).]
- Numerator statement: TOB-3: The number of patients who
received or refused evidence-based outpatient counseling AND received
or refused a prescription for FDA-approved cessation medication at
discharge TOB-3a: The number of patients who were referred to
evidence-based outpatient counseling AND received a prescription for
FDA-approved cessation medication at discharge.
- Denominator statement: The number of hospitalized
inpatients 18 years of age and older identified as current tobacco
users
- Exclusions: The exclusions to this measure are as follows:
1. Patients less than 18 years of age 2. Patients who are cognitively
impaired 3. Patients who are not current tobacco users 4. Patients
who refused or were not screened for tobacco use status during the
hospital stay (as tobacco status cannot be known) 5. Patients who
have a length of stay less than or equal to one day or greater than
120 days 6. Patients who expired during the hospital stay 7. Patients
who left against medical advice 8. Patients discharged/transferred to
another hospital for inpatient care 9. Patients
discharged/transferred to a federal health care facility 10. Patients
discharged/transferred to hospice 11. Patients who do not reside in
the United States
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Clinical Data, Facility
Discharge Data, Paper Medical Record
- Measure type: Process
- Steward: The Joint Commission
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported this endorsed measure
noting that it fills a gap in person-centered psychiatric care
through the identification and management of general medical
conditions. MAP noted that tobacco use is a common comorbid condition
in this population and half of smoking deaths are attributed to
people with mental illnesses. The measure is fully specified and
tested at the facility level.
- Public comments received: 4
Rationale for measure provided by HHS
Tobacco use is the
single greatest cause of disease in the United States today and accounts
for more than 435,000 deaths each year (CDC MMWR 2008; McGinnis 1993).
Smoking is a known cause of multiple cancers, heart disease, and stroke,
complications of pregnancy, chronic obstructive pulmonary disease,
other respiratory problems, poorer wound healing, and many other diseases
(DHHS 2004). Tobacco use creates a heavy cost to society as well as to
individuals. Smoking-attributable health care expenditures are estimated
at 96 billion dollars per year in direct medical expenses and 97 billion
dollars in lost productivity (CDC 2007). There is strong and consistent
evidence that tobacco dependence interventions, if delivered in a timely
and effective manner, significantly reduce the smoker’s risk of
suffering from tobacco-related disease and improved outcomes for those
already suffering from a tobacco-related disease (DHHS 2000; Baumeister
2007; Lightwood 2003 and 1997; Rasmussen 2005; Hurley 2005; Critchley
2004; Ford 2007; Rigotti 2008). Effective, evidence-based tobacco
dependence interventions have been clearly identified and include
clinician advice, individual, group, or telephone counseling, and use of
FDA-approved medications. These treatments are clinically effective
and extremely cost-effective relative to other commonly used disease
prevention interventions and medical treatments. Hospitalization (both
because hospitals are a tobacco-free environment and because patients may
be more motivated to quit as a result of their illness) offers an ideal
opportunity to provide cessation assistance that may promote the
patient’s medical recovery. Patients who receive even brief advice and
intervention from their care providers are more likely to quit than those
who receive no intervention. Studies indicate that the combination of
counseling and medications is more effective for tobacco cessation than
either medication or counseling alone, except in specific populations for
which there is insufficient evidence of the effectiveness of the
FDA-approved cessation medications. These populations include pregnant
women, smokeless tobacco users, light smokers, and adolescents. Tobacco
dependence should be viewed as a chronic disease. The treatment of this
chronic disease is most effective when the initial interventions provided
in the hospital setting are continued upon discharge to other care
settings.
Measure Specifications
- NQF Number (if applicable): 0647
- Description: Percentage of patients, regardless of age,
discharged from an inpatient facility (e.g., hospital inpatient or
observation, skilled nursing facility, or rehabilitation facility) to
home or any other site of care, or their caregiver(s), who received a
transition record (and with whom a review of all included information
was documented) at the time of discharge including, at a minimum, all
of the specified elements
- Numerator statement: Patients or their caregiver(s) who
received a transition record (and with whom a review of all included
information was documented) at the time of discharge including, at a
minimum, all of the following elements: Inpatient Care • Reason for
inpatient admission, AND • Major procedures and tests performed
during inpatient stay and summary of results, AND • Principal
diagnosis at discharge Post-Discharge/ Patient Self-Management •
Current medication list, AND • Studies pending at discharge (e.g.,
laboratory, radiological), AND • Patient instructionsAdvance Care
Plan • Advance directives or surrogate decision maker documented OR
• Documented reason for not providing care plan Contact
Information/Plan for Follow-up Care • 24-hour/7-day contact
information including physician for emergencies related to inpatient
stay, AND • Contact information for obtaining results of studies
pending at discharge, AND • Plan for follow-up care, AND • Primary
physician, other health care professional, or site designated for
follow-up care[Note: Numerator differs from posted MUC list based on
NQF staff analysis]
- Denominator statement: All patients, regardless of age,
discharged from an inpatient facility (e.g., hospital inpatient or
observation, skilled nursing facility, or rehabilitation facility) to
home/self-care or any other site of care.
- Exclusions: Patients who died. Patients who left against
medical advice (AMA) or discontinued care.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record
- Measure type: Process
- Steward: American Medical Association - Physician
Consortium for Performance Improvement
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported this measure for the
Inpatient Psychiatric Facility Quality Reporting program noting that
it is impactful and fills a gap in care coordination by ensuring that
patients receive important transition information. The measure is a
fully specified and tested endorsed measure. Members of the MAP also
noted that this type of measure shouldn't be exclusive to psychiatric
hospitals, but general acute hospitals as well, recommending
CMS consider this as an area for additional alignment. However,
several members also noted that this measure contains minimal
elements and may also overlap with conditions of participation for
these facilities.
- Public comments received: 5
Rationale for measure provided by HHS
This measure is
important to decrease cost, address gaps in care, and enhance
coordination of communication. Cost • In 2006, there were over 39 million
hospital discharges; of those, 13 percent of these patients are
repeatedly hospitalized and use 60 percent of the healthcare resources. •
A 2007 report by the Medicare Payment Advisory Commission estimated
approximately 18 percent of admissions result in readmissions within 30
days, costing CMS $15 billion. Gaps in Care: • Sabogal and colleagues
found that uncoordinated transitions between sites of care, even
within the same institution, and between caregivers increase hospital
readmissions, medical errors, duplication of services, and waste of
resources. • Moore and colleagues examined three types of discontinuity
of care among older patients transferred from the hospital: medication,
test result follow-up, and initiation of a recommended work-up. They
found that nearly 50 percent of hospitalized patients experienced at
least one discontinuity and that patients who did not have a recommended
work-up initiated were six times more likely to be re-hospitalized.
• A prospective, cross-sectional study by Roy and colleagues found that
approximately 40 percent of patients have pending test results at the
time of discharge and that 10 percent of these require some ac Emergency
Department Visits • The 2008 National Health Statistics Report
determined that 2.3 million (2 percent) emergency department visits are
from patients who were discharged from the hospital within the
previous 7 days. The report also cited the following: • Ten percent of
the 2.3 million emergency department visits were for complications
related to their recent hospitalization, and • The uninsured are 3 times
more likely to visit the emergency department. Medication errors: • An
estimated 60 percent of medication errors occur during times of
transition: upon admission, transfer, or discharge of a patient. • During
care transitions, patients receive medications from different
prescribers who rarely have access to patients’ comprehensive medication
list. • Forster and colleagues found that 19 percent of discharged
patients experienced an associated adverse event within three weeks of
leaving the hospital; 66 percent of these were adverse drug events.
Coleman EA, Min S, Chomiak A, Kramer AM. 2004. Post-hospital care
transitions: patterns, complications, and risk identification. Health
Services Research 39:1449–1465. Agency for Healthcare Research and
Quality (ARHQ). 1999. Outcomes by Patient and Hospital Characteristics
for All Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp.
Kramer A, Eilertsen T, Lin M, Hutt E. 2000. Effects of nurse staffing on
hospital transfer quality measures for new admissions. Pp. 9.1–9.22.
Inappropriateness of Minimum Nurse Staffing Ratios for Nursing Homes.
Health Care Financing Administration. Hutt E, Ecord M, Eilertsen TB, et
al. Precipitants of emergency room visits and acute hospitalization
in short-stay Medicare nursing home residents. J Am Geriatr Soc 2001;
50: 223-229. Jack BW, Chetty VK, Anthony D, et al. A reengineered
hospital discharge program to decrease rehospitalization. Ann Intern Med
2009; 150:178-187. Agency for Healthcare Research and Quality (ARHQ).
2006. Outcomes by Patient and Hospital Characteristics for All
Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp. Medicare
Payment Advisory Commission. A data book: Healthcare spending and the
Medicare program. June 2007. Available at:
http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf. Harris
G. Report finds a heavy toll from medication errors, N.Y. Times (July 21,
2006). Available at:
http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=5088&partner=rssnyt&emc=rss.
Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions
interventions: Improving patient safety and healthcare quality. CAHQ
Journal 2007 (Quarter 2). Moore C
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patient-drug days with
administration of anticoagulants requiring renal dosing with at least
one error in renal dosing
- Numerator statement: The total number of patient-drug days
with at least one renal dosing error.
- Denominator statement: The total number of patient-drug
days with administration of anticoagulants requiring renal
dosing.
- Exclusions: Admissions for individuals less than 18 years
old. 2. Admissions that are for observation only. 3. Admissions with
length of stay greater than or equal to 120 days. 4. Admissions with
length of stay less than 24 hours. 5. Drugs administered in the OR.
6. Admissions on dialysis of any kind. 7. Antibiotics given less than
2 hours prior to surgery and up to 24 hours post-surgery are ignored.
Ignore the first dose of antibiotic more than 2 hours before surgery
and the first dose more than 24 hours after surgery. 8. First 96
hours of drugs for patients with labor & delivery
codes.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP members agreed that this measure
addresses a critical gap in adverse drug events. Anticoagulants are a
high risk class of drugs that should be administered carefully to
renal patients, for whom the effects of many drugs differ from
non-renal patients. The MAP encouraged further development of this
measure at the facility level, testing, and submission to NQF for
endorsement.
- Public comments received: 4
Rationale for measure provided by HHS
Additional process
measure to assess medication adverse drug event associated with widely
used anticoagulants. The anticipated effect of implementing this measure
would be to reduce or eliminate inpatient anticoagulant dosing errors
that could lead to adverse drug events (ADEs) for patients with renal
impairment. Anticoagulants are one of three high risk drug classes
targeted in the National Action Plan for Adverse Drug Event Prevention.
Measure Specifications
- NQF Number (if applicable): 0642
- Description: Percentage of patients admitted to a hospital
with a primary diagnosis of an acute myocardial infarction or chronic
stable angina or who during hospitalization have undergone coronary
artery bypass (CABG) surgery, a percutaneous coronary intervention
(PCI), cardiac valve surgery (CVS), or cardiac transplantation who
are referred to an early outpatient cardiac
rehabilitation/secondary prevention program.
- Numerator statement: Number of eligible patients with a
qualifying event/diagnosis who have been referred to an outpatient
Cardiac Rehabilitation/Secondary Prevention (CR/SP) program prior to
hospital discharge or have a documented medical or patient-centered
reason why such a referral was not made.[For reference, additional
numerator text included for NQF endorsed measure on QPS: (Note: The
program may include a traditional CR/SP program based on face-to-face
interactions and training sessions or may include other options such
as home-based approaches. If alternative CR/SP approaches are
used, they should be designed to meet appropriate safety standards
and deliver effective, evidence-based services.)]
- Denominator statement: Number of hospitalized patients in
the reporting period hospitalized with a qualifying cardiovascular
disease event/diagnosis who do not meet any of the criteria listed in
the denominator exclusion section below.
- Exclusions: Exceptions criteria require documentation of
one or more of the following factors that may prohibit cardiac
rehabilitation participation: Patient factors (e.g., patient resides
in a long-term nursing care facility). Medical factors (e.g., patient
deemed by provider to have a medically unstable, life-threatening
condition). Health care system factors (e.g., no cardiac
rehabilitation/secondary prevention (CR/SP) program available within
60 min of travel time from the patient’s home). The only exclusion
criterion for this measure is noted below: Patients who expired
before discharge.
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: EHR, Paper Medical Record, Registry
- Measure type: Process
- Steward: American College of Cardiology
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditinal support pending resolution
of data concerns. MAP conditionally supported this measure pending
the resolution of specific data concerns. Specifically, the MAP would
like to see CMS collect this data directly from the registries for
hospitals that participate, and for those hospitals that do not
participate in these registries to allow them to submit this data
directly to CMS without the cost of participation in the registry.
MAP noted that ?this measure would address a known gap in care
transitions and referrals to the next site of care. MAP
acknowledged that cardiac rehabilitation has been found to be
underused, despite being included in the American Heart Association
Get with the Guidelines program and that referral is consistent with
best practices.
- Public comments received: 11
Rationale for measure provided by HHS
Cardiac
rehabilitation/secondary prevention programs (CR/SP) improve patient
outcomes, including quality of life, function, recurrent myocardial
infarction, and mortality. 2. CR/SP is underutilized with geographic
variability and decreased participation by patients with economic
disadvantages, women and older patients. 3. The CR/SP performance
measures were developed for use in systematic quality improvement
projects to close this treatment gap. 4. Use of systematic referral
processes and tools have been shown to increase CR/SP referral. 5.
Enrollment and participation in CR/SP, not referral, have been shown to
improve patient outcomes. However, referral is necessary for patients to
enroll and participate in CR/SP. The strength of provider referral
to CR has been shown to correlate with participation in CR.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending NQF review and endorsement. Members noted that this
measure addresses the cost of care an important condition. Other
members expressed caution on the use of this measure noting that
cellulitis is a highly variable condition that may be challenging to
measure using a episode-based framework. MAP encouraged the relevant
NQF Standing Committee to consider this issue in its review of this
measures for endorsement.
- Public comments received: 3
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)).
Measure Specifications
- NQF Number (if applicable): 0202
- Description: All documented patient falls with an injury
level of minor or greater on eligible unit types in a calendar
quarter. Reported as Injury falls per 1000 Patient Days. (Total
number of injury falls / Patient days) X 1000 Measure focus is
safety. Target population is adult acute care inpatient and adult
rehabilitation patients.
- Numerator statement: Total number of patient falls of
injury level minor or greater (whether or not assisted by a staff
member) by eligible hospital unit during the calendar month X
1000.[For reference, additional text about this NQF endorsed measure
from QPS:Included Populations: • Falls with Fall Injury Level of
“minor” or greater, including assisted and repeat falls with an
Injury level of minor or greater• Patient injury falls occurring
while on an eligible reporting unit Target population is adult acute
care inpatient and adult rehabilitation patients. Eligible unit types
include adult critical care, step-down, medical, surgical,
medical-surgical combined, critical access, adult rehabilitation
in-patient.]
- Denominator statement: Patient days by Type of Unit during
the calendar month.[For reference, additional text about this NQF
endorsed measure from QPS:Included Populations: •Inpatients, short
stay patients, observation patients, and same day surgery patients
who receive care on eligible inpatient units for all or part of a day
on the following unit types:•Adult critical care, step-down, medical,
surgical, medical-surgical combined, critical access and adult
rehabilitation inpatient units.•Patients of any age on an eligible
reporting unit are included in the patient day count.]
- Exclusions: Other unit types (e.g., pediatric,
psychiatric, obstetrical, etc.)
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Outcome
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending
applicability at the facility level. MAP conditionally suppoted this
measure pending demonstration of applicability at the facility level.
MAP noted that NQF #0141 and #0202 which are based off clinical data
could provider better information than claims based measure. The MAP
noted that falls are a common adverse event in hospitals, with
estimates of between 2-5 falls per 1,000 patient days. The group
noted that this is an important area for measurement as about 30% of
falls result in injury, disability, or death. Some MAP members
noted concerns that including this self-reported measure in IQR
could lead to underreporting.
- Public comments received: 15
Rationale for measure provided by HHS
The measure focus
addresses several national health goals and priorities, for example: 1.
Recently enacted Centers for Medicare and Medicaid Services regulations
limit hospital reimbursement for care related to fall related injuries.
2. The falls measures fits within the priorities set forth by the
National Priorities Parternship. Specifically, it fits within the
national priority of Making Care Safer (National Priorities Partnership,
2011). 3. As part of their National Patient Safety Goals, The Joint
Commission requires hospitals to reduce the risk of patient harm
resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini,
Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et
al., 2002, 2008). In quarter 3 of 2009, fall rates for nursing units in
participating NDNQI hospitals averaged 3.2 per 1000 patient days
(median = 2.8 per 1000 patient days). About 30% of falls result in
injury, disability, or death (Shorr, 2008) – particularly in older
adults. Injury falls lead to as much as a 61% increase in patient-care
costs and lengthen a patient’s hospital stay (Fitzpatrick, 2011).
Jorgensen (2011) estimated that by 2020 the direct and indirect costs of
injuries related to falls will reach $54.9 billion. In addition injury
falls are a significant source of liability for hospitals. Agnostini,
J.V., Baker, D.I., & Bogardus, S.T. (2001). Prevention of falls in
hospitalized and institutionalized older people. In Making health care
safer: A critical analysis of patient safety practices (pp. 281-299).
Evidence Report/Technology Assessment Number 43, AHRQ publication No.
01-E058. Rockville, MD: Agency for Healthcare Research and Quality.
Fitzpatrick, M.A. (2011, March). Meeting the challenge of fall reduction
[Supplement]. American Nurse Today, p. 1. Jorgensen, J. (2011, March).
Reducing patient falls: A call to action [Supplement]. American Nurse
Today, p. 2-3. National Priorities Partnership. (2011, September). Input
to the Secretary of Health and Human Services on Priorities for the
National Quality Strategy. Retrieved from:
http://www.qualityforum.org/Home.aspx Oliver, D., Connelly, J.B., Victor,
C.R. et al. (2007). Strategies to prevent falls and fractures in
hospitals and care homes and effect of cognitive impairment. 384, 82.
Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use,
restrain orders, and the risk of falls in hospitalized patients. Journal
of the American Geriatric Society, 50, 526-529. Shorr, R.I., Mion, L.C.,
Chandler, M., et al. (2008). Improving the capture of fall events
in hospitals: Combining a service for evaluating inpatient falls with an
incident report system. Journal of the American Geriatric Society, 56,
701-704. Unruh, L. (2002). Tends in adverse events in hospitalized
patients. Journal of Healthcare Quality, 24, 4-10.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending NQF review and endorsement. Members noted that this
measure addresses the cost of care for GI bleeding. Several members
expressed caution that the most efficient providers may reduce
overall hospitalizations thus those inpatient hospitalizations that
remain are a biased sample for measuring performance across
providers. The relevant NQF Standing Committee should consider these
issues in its review of these measures for endorsement.?
- Public comments received: 4
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 1
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)).
Measure Specifications
- NQF Number (if applicable): 0468
- Description: The measure estimates a hospital 30-day
risk-standardized mortality rate (RSMR), defined as death for any
cause within 30 days after the date of admission of the index
admission, for patients 18 and older discharged from the hospital
with a principal diagnosis of pneumonia. CMS annually reports the
measure for patients who are 65 years or older and are either
enrolled in fee-for-service (FFS) Medicare and hospitalized in
non-federal hospitals or are hospitalized in Veterans Health
Administration (VA) facilities.
- Numerator statement: The outcome for this measure is
30-day all-cause mortality. We define mortality as death from any
cause within 30 days of the index admission date for patients 18 and
older discharged from the hospital with a principal diagnosis of
pneumonia.[For reference, additional text on numerator included for
endorsed measure on QPS: The numerator of the risk-adjusted ratio is
the predicted number of deaths within 30 days given the hospital’s
performance with its observed case mix. The term “predicted”
describes the numerator result, which is calculated using the
hospital-specific intercept term. (See details below in the 2a1.13
Statistical risk model and variables.)]
- Denominator statement: The denominator includes patients
aged 18 and over admitted to an acute care hospital for pneumonia and
with a complete claims history for the 12 months prior to admission.
The measure is currently publicly reported by CMS for those 65 years
and older who are either Medicare FFS beneficiaries admitted to
non-federal hospitals or patients admitted to VA hospitals. In 2014,
we propose updating our current definition of pneumonia to include
patients with a principal discharge diagnosis of aspiration
pneumonia (defined by ICD-9-CM Code 507.0) and patients with a
principal discharge diagnosis of sepsis (defined by ICD-9-CM codes
995.91, 995.92, 038, 038.0, 038.1, 038.10, 038.11, 038.12, 038.19,
038.2,038.3, 038.4, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49,
038.8, 038.9, and 785.52) or respiratory failure (defined by ICD-9-CM
codes 518.81, 518.82. 518.84, and 799.1) and a secondary diagnosis of
pneumonia coded as present on admission (POA). Patients who are
transferred from one acute care facility to another must have a
principal discharge diagnosis of pneumonia at both hospitals. The
initial hospital for a transferred patient is designated as the
responsible institution for the episode.[For reference, denominator
for NQF endorsed measure on QPS: This claims-based measure can be
used in either of two patient cohorts: (1) patients aged 65 years or
older or (2) patients aged 18 years or older.The cohort includes
admissions for patients discharged from the hospital with a principal
discharge diagnosis of pneumonia and with a complete claims
history for the 12 months prior to admission.]
- Exclusions: The measure excludes index admissions for
patients: 1. Discharged alive on the day of admission or the
following day who were not transferred; 2. With inconsistent or
unknown vital status or other unreliable demographic data; 3.
Enrolled in the Medicare hospice program or VA hospice services any
time in the 12 months prior to the index admission, including the
first day of the index admission; and 4. Who were discharged against
medical advice (AMA). After the above exclusions (#1-4) are applied,
the measure randomly selects one index admission per patient per year
for inclusion in the cohort. Each episode of care must be mutually
independent with the same probability of the outcome. The
probability of death increases with each subsequent admission and
therefore the episodes of care are not mutually independent. For the
three year combined data, when index admissions occur during the
transition between measure reporting periods (June and July of each
year) and both are randomly selected for inclusion in the measure,
the measure only includes the June admission. The July admissions are
excluded from the measure to avoid assigning a single death to
two admissions.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review of the updates to this measure and continued endorsement. MAP
conditionally supported this measure pending NQF review of the
updates to this measure and continued endorsement. MAP reviewed a
revised version of this measure that would expand the cohort of
patients included in the measure to include patients with a primary
diagnoses of aspiration pneumonia and sepsis. The MAP noted that
pneumonia mortality remains an important area of hospital quality and
this expanded measure could potentially reduce coding biases.
This high-impact fully specified, tested and endorsed outcome
measure is already in use in several public and private programs
including IQR.
- Public comments received: 4
Rationale for measure provided by HHS
Among patients over
65 years of age, pneumonia is the second leading cause of
hospitalization, and is the leading infectious cause of death (Lindenauer
et al., 2011). Many current hospital interventions are known to decrease
the risk of death within 30 days of hospital admission (Jha et. al.,
2007). Current process-based performance measures, however, cannot
capture all the ways that care within the hospital might influence
outcomes. As a result, many stakeholders, including patient
organizations, are interested in outcomes measures that allow patients
and providers to assess relative outcomes performance for hospitals
(Bratzler et al., 2007). References: Bratzler, DW, Nsa W, Houck PM.
Performance measures for pneumonia: are they valuable, and are process
measures adequate. Current Opinion in Infectious Diseases. 20(2):182-189,
April 2007. Jha AK, Orav EJ, Li Z, Epstein AM. The inverse relationship
between mortality rates and performance in the Hospital Quality Alliance
measures. Health Aff (Millwood) 2007 Jul-Aug;26(4):1104-10. Lindenauer
PK, Normand SL, Drye EE, et al. Development, validation, and results
of a measure of 30-day readmission following hospitalization for
pneumonia. J Hosp Med. 2011;6(3):142-150
Measure Specifications
- NQF Number (if applicable): 0506
- Description: The measure estimates a hospital-level
risk-standardized readmission rate (RSRR) for patients discharged
from the hospital with a principal diagnosis of pneumonia. The
outcome is defined as unplanned readmission for any cause within 30
days of the discharge date for the index admission. A specified set
of planned readmissions do not count as readmissions. The target
population is patients 18 and over. CMS annually reports the measure
for patients who are 65 years or older and are either enrolled in
fee-for-service (FFS) Medicare and hospitalized in non-federal
hospitals or are hospitalized in Veterans Health Administration (VA)
facilities.
- Numerator statement: The outcome for this measure is
30-day readmission. We define readmission as an inpatient admission
for any cause, with the exception of certain planned readmissions,
within 30 days from the date of discharge from the index pneumonia
admission. If a patient has more than one unplanned admission within
30 days of discharge from the index admission, only the first one is
counted as a readmission. The measure looks for a dichotomous yes or
no outcome of whether each admitted patient has an unplanned
readmission within 30 days. However, if the first readmission after
discharge is considered planned, any subsequent unplanned readmission
is not counted as an outcome for that index admission because the
unplanned readmission could be related to care provided during
the intervening planned readmission rather than during the index
admission.
- Denominator statement: The denominator includes patients
18 and over hospitalized for pneumonia. The measure is currently
publicly reported by CMS for those 65 years and older who are either
Medicare FFS beneficiaries admitted to non-federal hospitals or
patients admitted to VA hospitals. In 2014, we propose updating our
current definition of pneumonia to include patients with a principal
discharge diagnosis of aspiration pneumonia (defined by ICD-9-CM Code
507.0) and patients with a principal discharge diagnosis of sepsis
(defined by ICD-9-CM codes 995.91, 995.92, 038, 038.0, 038.1,
038.10, 038.11, 038.12, 038.19, 038.2,038.3, 038.4, 038.40, 038.41,
038.42, 038.43, 038.44, 038.49, 038.8, 038.9, and 785.52) or
respiratory failure (defined by ICD-9-CM codes 518.81, 518.82.
518.84, and 799.1) and a secondary diagnosis of pneumonia coded as
present on admission (POA). To be included in the measure cohort used
in public reporting, patients must meet the following additional
inclusion criteria: enrolled in Part A and Part B Medicare for the 12
months prior to the date of admission, and enrolled in Part A
during the index admission (this criterion does not apply to
patients discharged from VA hospitals); not transferred to another
acute care facility; and alive at discharge.[For reference,
denominator for NQF endorsed measure in QPS: The target population
for this measure is patients aged 18 years and older discharged from
the hospital with a principal diagnosis of pneumonia with a complete
claims history for the 12 months prior to admission. The measure is
currently publicly reported by CMS for those 65 years and older who
are either Medicare FFS beneficiaries admitted to non-federal
hospitals or patients admitted to VA hospitals.As noted above, this
measure can also be used for an all-payer population aged 18 years
and older. We have explicitly tested the measure in both patients
aged 18+ years and those aged 65+ years.]
- Exclusions: For all cohorts, the measure excludes
admissions for patients: -Discharged against medical advice (AMA);
-Admitted with pneumonia within 30 days of discharge from a
qualifying index admission (Admissions within 30 days of discharge of
an index admission will be considered readmissions. No admission is
counted as a readmission and an index admission. The next eligible
admission after the 30-day time period following an index admission
will be considered another index admission.) For Medicare FFS
patients, the measure additionally excludes admissions for patients:
-Without at least 30 days post-discharge enrollment in FFS
Medicare
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review of the expanded measure and consideration for SDS adjustment
in the NQF trial period. MAP conditionally supported a revised
version of the measure that would expand the cohort of patients
included in the measure to include patients with a primary diagnoses
of aspiration pneumonia and sepsis for use in the IQR program. While
MAP members agreed that this is a high-impact outcome measure, part
of the MAP Safety Family of Measures, and in use in several public
and private programs, they did express caution over the
implementation of this updated version. MAP recommended that the
expanded measure be submitted for NQF endorsmenet and that CMS
implement the new measure in a way that minimizes confusion.The MAP
noted support of this measure on the condition that this measure is
considered for SDS adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual relationship between SDS
factors and pneumonia readmissions, and endorsed with appropriate
consideration of SDS factors if determined by NQF standing
committees.
- Public comments received: 6
Rationale for measure provided by HHS
The Medicare Payment
Advisory Commission (MedPAC) has called for hospital-specific public
reporting of readmission rates, identifying pneumonia as a priority
condition (MedPAC, 2007). MedPAC finds that readmissions are common,
costly, and often preventable. Based on 2005 Medicare data, MedPAC
estimates that about 8.9% of Medicare pneumonia admissions were followed
by a readmission within 15 days, accounting for more than 74,000
admissions at a cost of $533 million. Pneumonia results in approximately
1.2 million hospital admissions each year and accounts for more than $10
billion annually in hospital expenditures. Among patients over 65 years
of age, it is the second leading cause of hospitalization, and is the
leading infectious cause of death (Lindenauer et. al., 2011).
Approximately 20% of pneumonia patients were rehospitalized within thirty
days, representing the second-highest proportion of all
rehospitalizations at 6.3% (Jencks 2009). Pneumonia readmission is a
costly event and represents an undesirable outcome of care from the
patient’s perspective, and highly disparate pneumonia readmission rates
among hospitals suggest there is room for improvement. (MedPAC 2007,
Bernheim 2010). References: Bernheim SM, et al. 2010 Measures Maintenance
Technical Report: Acute Myocardial Infarction, Heart Failure and
Pneumonia 30-day Risk Standardized Mortality Rate. 2010 Available at:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier3&cid=1163010421830
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among
patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr
2;360(14):1418-28. Lindenauer PK, Normand SL, Drye EE, et al.
Development, validation, and results of a measure of 30-day readmission
following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
Report to the Congress: Promoting Greater Efficiency in Medicare.
Washington, DC: Medicare Payment Advisory Commission, 2007.
Measure Specifications
- NQF Number (if applicable):
- Description: This measure assesses days spent in acute
care after discharge from an acute care setting for an acute
myocardial infarction (AMI) hospitalization to provide a
patient-centered assessment of the post-discharge period. Acute care
utilization after discharge (return to the emergency department,
observation stay and readmission), for any reason, is disruptive to
patients and caregivers, costly to the healthcare system, and puts
patients at additional risk of hospital-acquired infections and
complications. Although some hospital returns are unavoidable, they
may also result from poor quality of care or inadequate transitional
care. When appropriate care transition processes are in place (for
example, patient is discharged to a suitable location,
communication occurs between clinicians, medications are correctly
reconciled, timely follow-up is arranged), fewer patients return to
an acute care setting, either for an emergency department (ED) visit,
observation stay, or hospital readmission during the 30 days
post-discharge. Therefore, this measure is intended to capture the
quality of care transitions provided to patients hospitalized with
AMI by collectively measuring a set of adverse outcomes that can
occur post-discharge: ED visits, unplanned observation stays, and
unplanned readmissions at any time during the 30 days
post-discharge. In order to aggregate all three events, we measure
each in terms of days of outcomes. Use of a day-count outcome
generates a clinically reasonable and natural weighting scheme such
that events that take more days (i.e. days rehospitalized) naturally
carry more weight than events taking fewer days (i.e. ED visits).
That is, the weight of each component of the composite is determined
by its actual impact and burden on patients, not by an arbitrary
weighting scheme. We then risk adjust the day count to account for
age, gender and comorbidity. The final reported outcome is
risk-standardized by subtracting the expected number of acute care
days from the predicted number. The risk-standardized days of acute
care are multiplied by 100 to represent risk-standardized days of
events per 100 admissions.
- Numerator statement: The outcome of the measure is the
number of days the patient spends in acute care (ED observation stay,
and readmission) during the first 30 days after discharge from the
hospital. The outcome can thus range from zero to 30 days, or zero to
300 per 100 discharges. An ED visit is defined as presence of revenue
center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation
stay is defined as revenue center code 0762 (in the outpatient file)
OR HCPCS G0378 (in the outpatient file) OR CPT codes
99217-99220 or 99234-99236 (in the carrier file). Days in which an ED
visit occurs are counted as 0.5 days of events since ED visits last
on average less than a day. ED visits that result in an observation
stay or readmission are not counted. Days of observation stay are
calculated on the basis of hours. Total hours are divided by 24 and
rounded up to the nearest integer. Any qualifying event in the 30-day
post-discharge window is included, except planned
readmissions, as defined by the planned readmission algorithm used in
the publicly reported CMS 30-day readmission measure for
AMI.
- Denominator statement: The target population for this
measure is patients aged 65 years and older hospitalized for AMI and
who are either Medicare Fee-for-Service (FFS) beneficiaries admitted
to non-federal hospitals or patients admitted to VA hospitals. An
index admission is the hospitalization to which the outcome is
attributed. These measures include index admissions for patients:
-Having a principal discharge diagnosis of AMI; -Enrolled in FFS or
are VA beneficiaries; -Aged 65 or over; -Discharged from
non-federal acute care hospitals or VA hospitals alive; -Not
transferred to another acute care facility; -and, Enrolled in Part A
and Part B Medicare for the 12 months prior to the date of the index
admission. This requirement is dropped for patients with an index
admission within a VA hospital. The denominator includes admissions
for patients discharged from the hospital with a principal diagnosis
of AMI International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) codes 410.00, 410.01, 410.10,
410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50,
410.51, 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90,
410.91.
- Exclusions: This measure excludes index admissions for
patients who leave the hospital against medical advice. This measure
also excludes index admissions for patients without at least 30 days
post-discharge enrollment in FFS Medicare (note that this exclusion
applies only to patients who have index admissions in non-VA
hospitals). An additional exclusion criterion for the AMI cohort is
that patients admitted and discharged on the same day are not
included as an index admission.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP was conditionally supportive of
this measure on the condition that this measure is reviewed by NQF
and endorsed. In particular, members noted that the measure should be
considered for SDS adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual relationship between SDS
factors and risk-standardized days following acute care, and endorsed
with appropriate consideration of SDS factors as determined by NQF
standing committees. Some MAP members noted this measure could
help address concerns about the growing use of observation
stays.
- Public comments received: 6
Rationale for measure provided by HHS
The goal of this
measure is to improve patient outcomes by providing patients, physicians,
and hospitals with information about hospital-level, risk-standardized
outcomes following hospitalization for AMI. Measurement of patient
outcomes allows for a broad view of quality of care that cannot be
captured entirely by individual process-of-care measures. Safely
transitioning patients from hospital to home requires a complex series of
tasks which would be cumbersome to capture individually as process
measures: timely and effective communication between providers,
prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and
emergency department evaluation. There already exist measures for
readmission, but there are no current measures for ED utilization and
observation stay. It is thus difficult for providers and consumers to
gain a complete picture of post-discharge outcomes. Moreover, separately
reporting each outcome encourages “gaming,” such as recategorizing
readmission stays as observation stays to avoid a readmission outcome. By
constructing a composite of outcomes that are important to
patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and
incentivizes global improvement in outcomes. Acute myocardial infarction
(AMI) is among the most common principal hospital discharge diagnoses
among Medicare beneficiaries, and, in 2008, it was the sixth most
expensive condition billed to Medicare, accounting for 4.8% of Medicare’s
hospital bill (Wier and Andrews, 2011). Readmission rates following
discharge for AMI are high. For example, between July 2005 and June 2008,
the median 30-day readmission rate for AMI was 19.9%, with a range
of 15.3% to 29.4% (Krumholz et al., 2009). Acute care utilization after
discharge (return to the emergency department, observation stay and
readmission), for any reason, is disruptive to patients and caregivers,
costly to the healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some
readmissions are unavoidable, they may also result from poor quality of
care or inadequate transitional care. Transitional care includes
effective discharge planning, transfer of information at the time of
discharge, patient assessment and education, and coordination of care
and monitoring in the post-discharge period. Numerous studies have found
an association between quality of inpatient or transitional care and
early (typically 30-day) readmission rates for a wide range of conditions
including AMI (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al.,
1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003;
Halfon et al., 2006; Bondestam et al., 1995; Carlhed et al., 2009).
Several studies have reported on the relationship between inpatient
admissions and other types of hospital care including ED visits and
observation stays. ED visits represent a significant proportion of
post-discharge acute care utilization. Two recent studies conducted in
patients of all ages have shown that 9.5% of patients return to the ED
within 30 days of hospital discharge and that about 12% of these patients
are discharged from the ED and are not captured by current CMS
readmissions measures (Rising et al., 2013; Vashi et al., 2013).
Additionally, over the past decade, the use of observation stays has
rapidly increased. Specifically, between 2001 and 2008, the use of
observation services increased nearly three-fold (Venkatesh et al., 2011)
and significant variation has been demonstrated in the use of observation
services for conditions such as chest pain (Schuur et al., 2011). These
rising rates of observation stays among Medicare beneficiaries have
gained the attention of
Measure Specifications
- NQF Number (if applicable):
- Description: This measure assesses days spent in acute
care after discharge from an acute care setting for a heart failure
hospitalization to provide a patient-centered assessment of the
post-discharge period. Acute care utilization after discharge (return
to the emergency department, observation stay and readmission), for
any reason, is disruptive to patients and caregivers, costly to the
healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some
hospital returns are unavoidable, they may also result from poor
quality of care or inadequate transitional care. When appropriate
care transition processes are in place (for example, patient is
discharged to a suitable location, communication occurs between
clinicians, medications are correctly reconciled, timely follow-up is
arranged), fewer patients return to an acute care setting, either for
an emergency department (ED) visit, observation stay, or hospital
readmission during the 30 days post-discharge. Therefore, this
measure is intended to capture the quality of care transitions
provided to patients hospitalized with heart failure by collectively
measuring a set of adverse outcomes that can occur post-discharge: ED
visits, unplanned observation stays, and unplanned readmissions at
any time during the 30 days post-discharge. In order to aggregate all
three events, we measure each in terms of days of outcomes. Use of a
day-count outcome generates a clinically reasonable and natural
weighting scheme such that events that take more days (i.e. days
rehospitalized) naturally carry more weight than events taking fewer
days (i.e. ED visits). That is, the weight of each component of the
composite is determined by its actual impact and burden on patients,
not by an arbitrary weighting scheme. We then risk adjust the day
count to account for age, gender and comorbidity. The final reported
outcome is risk-standardized by subtracting the expected number of
acute care days from the predicted number. The risk-standardized
days of acute care are multiplied by 100 to represent
risk-standardized days of events per 100 admissions.
- Numerator statement: The outcome of the measure is the
number of days the patient spends in acute care (ED observation stay,
and readmission) during the first 30 days after discharge from the
hospital. The outcome can thus range from zero to 30 days, or zero to
300 per 100 discharges. An ED visit is defined as presence of revenue
center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation
stay is defined as revenue center code 0762 (in the outpatient file)
OR HCPCS G0378 (in the outpatient file) OR CPT codes
99217-99220 or 99234-99236 (in the carrier file). Days in which an ED
visit occurs are counted as 0.5 days of events since ED visits last
on average less than a day. ED visits that result in an observation
stay or readmission are not counted. Days of observation stay are
calculated on the basis of hours. Total hours are divided by 24 and
rounded up to the nearest integer. Any qualifying event in the 30-day
post-discharge window is included, except planned
readmissions, as defined by the planned readmission algorithm used in
the publicly reported CMS 30-day readmission measure for heart
failure.
- Denominator statement: The target population for this
measure is patients aged 65 years and older hospitalized for heart
failure and who are either Medicare Fee-for-Service (FFS)
beneficiaries admitted to non-federal hospitals or patients admitted
to VA hospitals. An index admission is the hospitalization to which
the outcome is attributed. These measures include index admissions
for patients: -Having a principal discharge diagnosis of heart
failure; -Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65
or over; -Discharged from non-federal acute care hospitals or VA
hospitals alive; -Not transferred to another acute care facility;
-and, Enrolled in Part A and Part B Medicare for the 12 months prior
to the date of the index admission. This requirement is dropped for
patients with an index admission within a VA hospital. The
denominator includes admissions for patients discharged from the
hospital with a principal diagnosis of heart failure International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11,
404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23,
428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42,
428.43, 428.9.
- Exclusions: This measure excludes index admissions for
patients who leave the hospital against medical advice. This measure
also excludes index admissions for patients without at least 30 days
post-discharge enrollment in FFS Medicare (note that this exclusion
applies only to patients who have index admissions in non-VA
hospitals).
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP was conditionally supportive of
this measure on the condition that this measure is reviewed by NQF
and endorsed. In particular, members noted that the measure should be
considered for SDS adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual relationship between SDS
factors and risk-standardized days following acute care, and endorsed
with appropriate consideration of SDS factors as determined by NQF
standing committees. Some MAP members noted this measure could
help address concerns about the growing use of observation
stays.
- Public comments received: 7
Rationale for measure provided by HHS
The goal of this
measure is to improve patient outcomes by providing patients, physicians,
and hospitals with information about hospital-level, risk-standardized
outcomes following hospitalization for heart failure. Measurement of
patient outcomes allows for a broad view of quality of care that cannot
be captured entirely by individual process-of-care measures. Safely
transitioning patients from hospital to home requires a complex series of
tasks which would be cumbersome to capture individually as process
measures: timely and effective communication between providers,
prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and
emergency department evaluation. There already exist measures for
readmission, but there are no current measures for ED utilization and
observation stay. It is thus difficult for providers and consumers to
gain a complete picture of post-discharge outcomes. Moreover, separately
reporting each outcome encourages “gaming,” such as recategorizing
readmission stays as observation stays to avoid a readmission outcome. By
constructing a composite of outcomes that are important to
patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and
incentivizes global improvement in outcomes. Heart failure is the most
common principal discharge diagnosis among older adults and the third
highest for hospital reimbursements in 2005 (CMS, 2006) and the leading
cause of death and readmission among Medicare beneficiaries, with nearly
half of heart failure patients expected to return to the hospital within
six months of discharge (Jencks et al., 2009; Krumholz et al.,
1997; Lloyd-Jones et al., 2010). Readmission rates following discharge
for heart failure are high and variable across hospitals in the United
States (Krumholz et al., 2009; Bernheim et al., 2010). For example, for
the time period of July 2011-June 2012, publicly reported 30-day
risk-standardized readmission rates ranged from 17.5% to 30.3% for
patients admitted with heart failure (CMS, 2013) Acute care utilization
after discharge (return to the emergency department, observation
stay and readmission), for any reason, is disruptive to patients and
caregivers, costly to the healthcare system, and puts patients at
additional risk of hospital-acquired infections and complications.
Although some readmissions are unavoidable, they may also result from
poor quality of care or inadequate transitional care. Transitional care
includes effective discharge planning, transfer of information at the
time of discharge, patient assessment and education, and coordination of
care and monitoring in the post-discharge period. Numerous studies
have found an association between quality of inpatient or transitional
care and early (typically 30-day) readmission rates for a wide range of
conditions including heart failure (Frankl et al., 1991; Corrigan et al.,
1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000;
Courtney et al., 2003; Halfon et al., 2006; Hernandez et al., 2010).
Several studies also have reported on the relationship between inpatient
admissions and other types of hospital care including ED visits and
observation stays. ED visits represent a significant proportion of
post-discharge acute care utilization. Two recent studies conducted in
patients of all ages have shown that 9.5% of patients return to the ED
within 30 days of hospital discharge and that about 12% of these patients
are discharged from the ED and are not captured by current CMS
readmissions measures (Rising et al., 2013; Vashi et al., 2013).
Additionally, over the past decade, the use of observation stays has
rapidly increased. Specifically, between 2001 and 2008, the use of
observation services incre
Measure Specifications
- NQF Number (if applicable):
- Description: This measure assesses days spent in acute
care after discharge from an acute care setting for a pneumonia
hospitalization to provide a patient-centered assessment of the
post-discharge period. Acute care utilization after discharge (return
to the emergency department, observation stay and readmission), for
any reason, is disruptive to patients and caregivers, costly to the
healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some
hospital returns are unavoidable, they may also result from poor
quality of care or inadequate transitional care. When appropriate
care transition processes are in place (for example, patient is
discharged to a suitable location, communication occurs between
clinicians, medications are correctly reconciled, timely follow-up is
arranged), fewer patients return to an acute care setting, either for
an emergency department (ED) visit, observation stay, or hospital
readmission during the 30 days post-discharge. Therefore, this
measure is intended to capture the quality of care transitions
provided to patients hospitalized with pneumonia by collectively
measuring a set of adverse outcomes that can occur post-discharge: ED
visits, unplanned observation stays, and unplanned readmissions at
any time during the 30 days post-discharge. In order to aggregate all
three events, we measure each in terms of days of outcomes. Use of a
day-count outcome generates a clinically reasonable and natural
weighting scheme such that events that take more days (i.e. days
rehospitalized) naturally carry more weight than events taking fewer
days (i.e. ED visits). That is, the weight of each component of the
composite is determined by its actual impact and burden on patients,
not by an arbitrary weighting scheme. We then risk adjust the day
count to account for age, gender and comorbidity. The final reported
outcome is risk-standardized by subtracting the expected number of
acute care days from the predicted number. The risk-standardized
days of acute care are multiplied by 100 to represent
risk-standardized days of events per 100 admissions.
- Numerator statement: The outcome of the measure is the
number of days the patient spends in acute care (ED observation stay,
and readmission) during the first 30 days after discharge from the
hospital. The outcome can thus range from zero to 30 days, or zero to
300 per 100 discharges. An ED visit is defined as presence of revenue
center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation
stay is defined as revenue center code 0762 (in the outpatient file)
OR HCPCS G0378 (in the outpatient file) OR CPT codes
99217-99220 or 99234-99236 (in the carrier file). Days in which an ED
visit occurs are counted as 0.5 days of events since ED visits last
on average less than a day. ED visits that result in an observation
stay or readmission are not counted. Days of observation stay are
calculated on the basis of hours. Total hours are divided by 24 and
rounded up to the nearest integer. Any qualifying event in the 30-day
post-discharge window is included, except planned
readmissions, as defined by the planned readmission algorithm used in
the publicly reported CMS 30-day readmission measure for
pneumonia.
- Denominator statement: The target population for this
measure is patients aged 65 years and older hospitalized for
pneumonia and who are either Medicare Fee-for-Service (FFS)
beneficiaries admitted to non-federal hospitals or patients admitted
to VA hospitals. An index admission is the hospitalization to which
the outcome is attributed. These measures include index admissions
for patients: -Having a principal discharge diagnosis of pneumonia;
-Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65 or over;
-Discharged from non-federal acute care hospitals or VA
hospitals alive; -Not transferred to another acute care facility;
-and, Enrolled in Part A and Part B Medicare for the 12 months prior
to the date of the index admission. This requirement is dropped for
patients with an index admission within a VA hospital. The
denominator includes admissions for patients discharged from the
hospital with a principal diagnosis of pneumonia International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) codes 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 481,
482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41,
482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9,
483.0, 483.1, 483.8, 485, 486, 487.0, and 488.11; ICD-10-CM codes
J120, J121, J122, J1281, J1289, J129, J13, J181, J150, J151, J14,
J154, J154, J153, J154, J1520, J1521, J1521, Z16, J1529, J158, J155,
J156, A481, J158, J159, J157, J160, J168, J180, J189, J1100, J129,
J09119).
- Exclusions: This measure excludes index admissions for
patients who leave the hospital against medical advice. This measure
also excludes index admissions for patients without at least 30 days
post-discharge enrollment in FFS Medicare (note that this exclusion
applies only to patients who have index admissions in non-VA
hospitals).
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP was conditionally supportive of
this measure on the condition that this measure is reviewed by NQF
and endorsed. In particular, members noted that the measure should be
considered for SDS adjustment in the upcoming NQF trial period,
reviewed for the empirical and conceptual relationship between SDS
factors and risk-standardized days following acute care, and endorsed
with appropriate consideration of SDS factors as determined by NQF
standing committees. Some MAP members noted this measure could
help address concerns about the growing use of observation
stays.
- Public comments received: 6
Rationale for measure provided by HHS
The goal of this
measure is to improve patient outcomes by providing patients, physicians,
and hospitals with information about hospital-level, risk-standardized
outcomes following hospitalization for pneumonia. Measurement of patient
outcomes allows for a broad view of quality of care that cannot be
captured entirely by individual process-of-care measures. Safely
transitioning patients from hospital to home requires a complex series of
tasks which would be cumbersome to capture individually as process
measures: timely and effective communication between providers,
prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and
emergency department evaluation. There already exist measures for
readmission, but there are no current measures for ED utilization and
observation stay. It is thus difficult for providers and consumers to
gain a complete picture of post-discharge outcomes. Moreover, separately
reporting each outcome encourages “gaming,” such as recategorizing
readmission stays as observation stays to avoid a readmission outcome. By
constructing a composite of outcomes that are important to
patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and
incentivizes global improvement in outcomes. Pneumonia results in
approximately 1.2 million hospital admissions each year and accounts for
more than $10 billion annually in hospital expenditures. Among patients
over 65 years of age, it is the second leading cause of hospitalization,
and is the leading infectious cause of death (Lindenauer et al.,
2011). Approximately 20% of pneumonia patients were rehospitalized within
thirty days, representing the second-highest proportion of all
rehospitalizations at 6.3% (Jencks et al., 2009). Acute care utilization
after discharge (return to the emergency department, observation stay and
readmission), for any reason, is disruptive to patients and
caregivers, costly to the healthcare system, and puts patients at
additional risk of hospital-acquired infections and complications.
Although some readmissions are unavoidable, they may also result from
poor quality of care or inadequate transitional care. Transitional care
includes effective discharge planning, transfer of information at the
time of discharge, patient assessment and education, and coordination of
care and monitoring in the post-discharge period. Numerous studies
have found an association between quality of inpatient or transitional
care and early (typically 30-day) readmission rates for a wide range of
conditions including pneumonia (Frankl et al., 1991; Corrigan et al.,
1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000;
Courtney et al., 2003; Halfon et al., 2006; Dean et al., 2006). Several
studies also have reported on the relationship between inpatient
admissions and other types of hospital care including ED visits and
observation stays. ED visits represent a significant proportion of
post-discharge acute care utilization. Two recent studies conducted in
patients of all ages have shown that 9.5% of patients return to the ED
within 30 days of hospital discharge and that about 12% of these patients
are discharged from the ED and are not captured by current CMS
readmissions measures (Rising et al., 2013; Vashi et al., 2013).
Additionally, over the past decade, the use of observation stays has
rapidly increased. Specifically, between 2001 and 2008, the use of
observation services increased nearly three-fold (Venkatesh et al., 2011)
and significant variation has been demonstrated in the use of observation
services for conditions such as chest pain (Schuur et al., 2011). These
rising rates of observation stays among Medicare beneficiaries have
gained the attention of patients
Measure Specifications
- NQF Number (if applicable):
- Description: This measure estimates hospital-level,
risk-standardized payments for a primary elective total THA/TKA
episode of care starting with inpatient admission to a short term
acute-care facility for Medicare fee-for-service (FFS) patients who
are 65 years of age or older.
- Numerator statement: Outcome: hospital-level,
risk-standardized payment for Medicare patients for a primary
elective total hip and/or knee arthroplasty episode of care. Payment
timeframe: admission date through 90 days
post-admission.
- Denominator statement: Admissions for Medicare FFS
patients: with qualifying THA/TKA procedure; Aged 65 or over;
Admitted to non-federal acute care hospitals; Enrolled in Medicare
Parts A and B for index and 12 months prior; Not transferred from
acute care facility.
- Exclusions: Patients without complete administrative data
in the 90 days following the index admission, if alive 2) Patients
with no payment information during the index admission 3) Patients
discharged against medical advice (AMA) 4) Patients transferred to
federal hospitals 5) Patients with more than two THA/TKA procedure
codes during the admission
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims, Chronic Condition
Data Warehouse (CCW), Other (please list in GTL comment
field)
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending a timely review of these measures by the NQF Cost and
Resource Use Standing Committee to consider harmonization issues and
determine the most parsimonious approach to measuring the costs of
hip and knee replacements to minimize the burden and confusion of
competing methodologies.? MAP noted that Joint replacement surgeries
are becoming more commonly utilized as Medicare covered 337,419
THA procedures and 750,569 TKA procedures between 2009 and 2012
and annual Medicare payments for THA and TKA exceed $15 billion
annually. The group noted that there is significant variation in
costs for these procedures that are often related to quality of care
as complications and readmissions increase the total payment for
post-surgical care.
- Public comments received: 3
Rationale for measure provided by HHS
Due to their
frequency and cost, THA and TKA are priority areas for outcome measure
development. More than one third of the US population 65 years and older
suffers from osteoarthritis [1]. Between 2009 and 2012, there were
337,419 THA procedures and 750,569 TKA procedures for Medicare
fee-for-service patients 65 years and older [2]. Estimates place the
annual insurer cost of osteoarthritis in the US at $149 billion, with
Medicare direct payments to hospitals for THA/TKA exceeding $15 billion
annually [3]. Further, there are conflicting data regarding costs after
total joint arthroplasty, with evidence to support both increased
[4] and decreased costs [5] following arthroplasty, suggesting there is
great variation in the costs of a full episode of care for THA and TKA.
Clinical outcomes for THA and TKA depend not only on the surgeon
performing the procedure, but on care coordination across provider groups
and specialties, and the patient’s engagement in his or her recovery.
Even the very best surgeon will not get outstanding results if there are
gaps in the quality of care for the patient before, during, and after
surgery. The goal of hospital-level resource use measurement is to
capture the full spectrum of care in order to incentivize collaboration
and shared responsibility for improving patients’ health and reducing
the burden of their disease. Variation in the cost of a THA or TKA
episode of care is often related to the quality of care, where
complications and readmissions increase the total payment for
post-surgical care. Given the well-documented variation in readmission
and complication rates following THA and TKA, there is expected variation
in total episode of care costs for the procedures [6]. Birkmeyer et al.
found that the average 30-day cost increased by $2,436 among
hospitals with the highest quintile of complication rates, compared to
the lowest quintile following THA [7]. The same study also found that
rehabilitation costs accounted for 50% of “excess” payments among those
undergoing THA. Miller et al. found that a major driver of differences in
episode payments for THA was that hospitals within Accountable Care
Organizations (ACO) had smaller payments for post-discharge care compared
to non-ACO hospitals [8]. Taken together, these studies suggest
that much of the variation in total episode costs arises in the
post-acute setting. Health systems have taken notice of opportunities to
improve value by encouraging collaboration of care between hospitals and
post-acute providers. The Centers for Medicare & Medicaid Services’
(CMS’s) Bundled Payment for Care Improvement initiative aims to assess
the feasibility and effectiveness of various models of bundled payments
[9]. One analysis of hospitals found that the overall episode of care,
particularly post-discharge care, was less expensive in hospitals
affiliated with Integrated Delivery Systems [10]. Transparency regarding
the variation of episode of care payments triggered by THA and TKA helps
to guide health systems and providers towards improvement in the value of
care. 1. Centers for Disease Control and Prevention (CDC).
Osteoarthritis. 2011;
http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed August
13, 2013. 2. Suter LG, Grady JN, Lin Z, et al. 2013 Measure Updates and
Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or
Total Knee Arthroplasty (TKA) All-Cause Unplanned 30-Day
Risk-Standardized Readmission Measure (Version 2.0). March 2013. 3.
Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large
variations in Medicare payments for surgery highlight savings potential
from bundled payment programs. Health affairs (Project Hope). Nov
2011;30(11):2107-2115. 4. Bozic KJ, Stacey B, Berger A, Sadosky A, Oster
G. Resource utilization and costs before and after total joint
arthroplasty. BMC health services research. 2012;12:73. 5. Hawker GA,
Badley EM, Croxford R, et al. A population-based nested case-control stud
Measure Specifications
- NQF Number (if applicable):
- Description: This eMeasure estimates the hospital-level,
risk-standardized rate of unplanned, all-cause readmission after
admission for any eligible condition within 30 days of hospital
discharge (RSRR). The eMeasure reports a single summary RSRR, derived
from the volume-weighted results of five different models, one for
each of the following specialty cohorts (grouped by discharge
condition categories or procedure categories): surgery/gynecology,
general medicine, cardiorespiratory, cardiovascular, and neurology.
The eMeasure also indicates the hospital standardized risk
ratios (SRR) for each of these five specialty cohorts. This eMeasure
is a re-engineering of measure 1789, the Hospital-Wide All-Cause
Risk-Standardized Readmission Measure developed for patients 65 years
and older using Medicare claims. This reengineered measure uses
clinical data elements from patients’ electronic health records for
risk adjustment in addition to claims data.
- Numerator statement: The outcome for this measure is
unplanned all-cause 30-day readmission. We defined a readmission as
an inpatient admission to any acute care facility which occurs within
30 days of the discharge date of an earlier, eligible index
admission.
- Denominator statement: Admissions for patients: Who are
matched in the EHR/claims data; Enrolled in Medicare FFS; Aged 65 or
over; Discharged from non-federal acute care hospitals; Discharged
alive; Not transferred to an acute care facility; Enrolled in Part A
for 12 mo prior
- Exclusions: The measure excludes admissions for patients:
•Admitted to Prospective Payment System (PPS)-exempt cancer hospitals
Rationale: These hospitals care for a unique population of patients
that cannot reasonably be compared to patients admitted to other
hospitals •Without at least 30 days of post-discharge enrollment in
FFS Medicare Rationale: The 30-day readmission outcome cannot be
assessed in this group since claims data are used to determine
whether a patient was readmitted. •Discharged against medical advice
(AMA) Rationale: Providers did not have the opportunity to deliver
full care and prepare the patient for discharge. •Admitted for
primary psychiatric diagnoses Rationale: Patients admitted for
psychiatric treatment are typically cared for in separate psychiatric
or rehabilitation centers that are not comparable to acute care
hospitals. •Admitted for rehabilitation Rationale: These admissions
are not typically to an acute care hospital and are not for acute
care. •Admitted for medical treatment of cancer Rationale: These
admissions have a different mortality and readmission profile than
the rest of the Medicare population, and outcomes for these
admissions do not correlate well with outcomes for other admissions.
Patients with cancer admitted for other diagnoses or for
surgical treatment of their cancer remain in the measure.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Hybrid
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: While the claims version of this
measure is NQF-endorsed (1789 Hospital-Wide All-Cause Unplanned
Readmission Measure (HWR)) is already a part of the Hospital
Inpatient Quality Reporting, the e-Measure version of this measure is
in alpha testing. The MAP supported continued development of this
measure noting the potential to improve the measure risk adjustment
model by including available clinical data. Further, members
highlighted the need to review the conceptual and empirical
relationship between SDS factors and this outcome and including such
variables if appropriate.
- Public comments received: 7
Rationale for measure provided by HHS
Currently, the
Centers for Medicare & Medicaid Services (CMS) publicly reports
risk-standardized readmission rates (RSRRs) for several conditions,
including acute myocardial infarction (AMI), heart failure (HF),
pneumonia, and hip and knee arthroplasty. CMS has also developed hospital
readmission measures for stroke and chronic obstructive pulmonary disease
(COPD). While it is helpful to assess readmission rates for
specific groups of patients, these conditions account for only a small
proportion of total readmissions. In 2013, CMS began publicly reporting a
hospital-wide, all-condition readmission measure which provides a broader
assessment of the quality of care at hospitals. This measure, which uses
the same cohort and outcome definitions as the proposed eMeasure,
includes 93% of admissions to acute care non-federal hospitals of
Medicare Fee-for-Service patients over age 65 who are discharged alive to
the non-acute care setting. The measure captures 92% of
readmissions following eligible admissions. The proposed measure will
build on the hospital-wide readmission measure by using clinical data
elements derived from electronic health records (EHR), such as laboratory
test values and vital signs, to risk adjust for patient-level factors
that influence readmission. The proliferation of EHR systems and
standardization of extraction and reporting of clinical data for quality
measurement provide an opportunity to integrate these data into measures
of hospital performance. This effort is also responsive to the preference
expressed by the clinical community for the use of clinical data
to adjust for patients’ severity of illness in hospital outcome measures.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending NQF review and endorsement. Members noted that this
measure addresses the cost of care for common conditions. Kidney/UTIs
are mainly treated on an outpatient basis but the cost of care can be
high if hospitalization and follow-up is required. Other members
expressed caution that the most efficient providers may reduce
overall hospitalizations thus those hospitalizations that remain are
a biased sample for measuring performance across providers. The
relevant NQF Standing Committee should consider these issues in its
review of these measures for endorsement.
- Public comments received: 5
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 2
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)).
Measure Specifications
- NQF Number (if applicable):
- Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to
avoid bladder and urethral trauma, keeping the urine collection bag
below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI
monitoring, leads to improved patient outcomes and provides a
mechanism for identifying improvements and quality efforts.
- Numerator statement: Total number of observed
healthcare-associated CAUTI among patients in bedded inpatient care
locations (excluding patients in Level II or III neonatal
ICUs).
- Denominator statement: S.7. Denominator Statement: Total
number of indwelling urinary catheter days for each location under
surveillance for CAUTI during the data period. S.10. Denominator
Exclusions: The following are not considered indwelling catheters by
NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In
and out” catheterizations 4. Nephrostomy tubes Note, that if a
patient has either a nephrostomy tube or a suprapubic catheter and
also has an indwelling urinary catheter, the indwelling urinary
catheter will be included in the CAUTI surveillance.
- Exclusions: The following are not considered indwelling
catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom
catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note,
that if a patient has either a nephrostomy tube or a suprapubic
catheter and also has an indwelling urinary catheter, the indwelling
urinary catheter will be included in the CAUTI
surveillance.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supported the implementation of
an updated version of this measure currently in the IQR Program. This
update was recently reviewed and recommended by the NQF Safety
Standing Committee. Implementing this updated measure would extend
the measure to hospital settings outside the ICU and add another risk
adjustment methodology. The two risk adjustment methodologies are:
Standardized Infection Ratio (SIR) uses a stratification approach to
compare CAUTIs incidence rates. For example, the stratification can
be by the hospital’s patient care location as the predicted number of
CAUTIs in a medical ICU may be different then a general
medical/surgical unit. Adjusted Ranking Metric (ARM) uses a more
complex Bayesian estimation technique to account for the small sample
sizes that may be present in the strata described in the SIR above.
To adjust for this potentially low precision and/or reliability due
to sample size, a statistical adjustment is made to the numerator.
The MAP was supportive of using this measure in the IQR program to
gain some experience in the measure for CMS and providers. Expanding
the measure from the ICU to other locations in the hospital
significantly adjusts the measure and experience is needed. The MAP
also acknowledged concerns raised by providers specializing in the
treatment of spinal cord injuries and encouraged further
consideration on the trade-offs of including these patients in this
measure population. Finally, several MAP members noted that the ARM
calculation is very difficult to replicate without coefficients from
CDC and urged CDC and CMS to make all elements of the calculation
transparent.
- Public comments received: 6
Rationale for measure provided by HHS
Measure has been
revised and now in NQF re-endorsement process. CAUTI can be minimized by
a collection of prevention efforts. These include reducing the number of
unnecessary indwelling catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters to the patient´s leg
to avoid bladder and urethral trauma, keeping the urine collection
bag below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this measure
to track CAUTIs through a nationalized standard for HAI monitoring, leads
to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another
risk adjustment methodology besides the Standardized Infection Ratio. The
two risk adjustment methodologies are: 1. Standardized Infection Ratio
(annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any
number of stratified groups of data. CAUTI incidence rates stratified by
patient care location type and in some instances, location bed size
and type of medical school affiliation which form the basis of the
population standardization. Example: predicted numbers of CAUTI (and
CAUTI rates) in a medical ICU are not the same as in an SICU. See also
Scientific Validity section for further information on risk adjustment
and variables. 2. Adjusted Ranking Metric (annual aggregation) The
adjusted ranking metric (ARM) combines the method of indirect
standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in
the unadjusted SIR mentioned above. A Bayesian posterior
distribution constructed through Monte Carlo Markov Chain sampling is
used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable):
- Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of
lines are recommended. These efforts result in decreased morbidity
and mortality and reduced healthcare costs.
- Numerator statement: Total number of observed
healthcare-associated CLABSI among patients in bedded inpatient care
locations.
- Denominator statement: S.7. Denominator Statement: Total
number of central line days for each location under surveillance for
CLABSI during the data period. S.10. Denominator Exclusions: 1.
Pacemaker wires and other non-lumened devices inserted into central
blood vessels or the heart are excluded as CLs. 2. Extracorporeal
membrane oxygenation lines, femoral arterial catheters, intraaortic
balloon pump devices, and hemodialysis reliable outflow
catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines
are excluded as CLs.
- Exclusions: Pacemaker wires and other non-lumened devices
inserted into central blood vessels or the heart are excluded as CLs.
2. Extracorporeal membrane oxygenation lines, femoral arterial
catheters, intraaortic balloon pump devices, and hemodialysis
reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral
intravenous lines are excluded as CLs.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP was supportive of including this
structural measure in the IQR program. Workgroup members noted that
participation in a patient safety culture survey is an important
element to building a system of quality improvement within health
care facilities. While some MAP members noted that ideally results of
a patient safety culture survey would be made publiclly available,
the group agreed that there are limitations to reporting the results
of the tools currently used such as the use of two different surveys
that can not be cross-referenced.
- Public comments received: 1
Rationale for measure provided by HHS
Updated version of a
current measure in IQR, HVBP, and HACRP CLABSI can be minimized through
proper management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs. Use of this measure to track
CLABSIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and evaluating prevention efforts. Additionally, CDC has
added another risk adjustment methodology besides the Standardized
Infection Ratio. The two risk adjustment methodologies are: 1.
Standardized Infection Ratio (annual and quarter aggregation) The SIR is
constructed by using an indirect standardization method for summarizing
HAI experience across any number of stratified groups of data.
CLABSI incidence rates stratified by patient care location type and in
some instances, location bed size and type of medical school affiliation
which form the basis of the population standardization. Example:
predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the
method of indirect standardization with a Bayesian random effects
hierarchical model to account for the potentially low precision and/or
reliability inherent in the unadjusted SIR mentioned above. A Bayesian
posterior distribution constructed through Monte Carlo Markov Chain
sampling is used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable): 0205
- Description: NSC-13.1 (RN hours per patient day) – The
number of productive hours worked by RNs with direct patient care
responsibilities per patient day for each in-patient unit in a
calendar month. NSC-13.2 (Total nursing care hours per patient day) –
The number of productive hours worked by nursing staff (RN,LPN/LVN,
and UAP) with direct patient care responsibilities per patient day
for each in-patient unit in a calendar month. Measure focus is
structure of care quality in acute care hospital units.
- Numerator statement: Total number of productive hours
worked by nursing staff with direct patient care responsibilities for
each hospital inpatient unit during the calendar month.
- Denominator statement: Denominator is the total number of
patient days for each in-patient unit during the calendar month.
Patient days must be from the same unit in which nursing care hours
are reported.
- Exclusions: Patient days from some non-reporting unit
types, such as Emergency Department, peri-operative unit, and
obstetrics, are excluded.
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims, Administrative
Clinical Data, Facility Discharge Data, EHR, Paper Medical Record,
Other (please list in GTL comment field)
- Measure type: Structure
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review and endorsement of this measure at the facility level. MAP was
conditionally supportive of this measure pending NQF review and
endorsement of this measure at the facility level. Additionally, MAP
noted the need for resolution of data issues, specifically that
hospitals participating in the NDNQI program can have their data
directly shared with CMS while those that do not currently
participate in that program have the opportunity to send their data
directly to CMS. Some members noted that there is no gold standard
for this measure and thus it is difficult to access relative
performance on this measure.
- Public comments received: 8
Rationale for measure provided by HHS
With the increasing
concerns about cost and quality of patient care over the past 2 decades,
hospital nurse staffing has become a major focus in examining health care
workforce relationships with patient outcomes. Nurses are the largest
group of clinical providers of care in healthcare systems. The Institute
of Medicine recently concluded, in its report, The Future of
Nursing: Leading Changing, Advancing Health (2010), that nurses are vital
in providing quality care to patients. A large body of research has
demonstrated that higher nurse staffing levels are significantly
associated with better patient outcomes, including shorter length of stay
and lower rates of mortality, failure to rescue, hospital acquired
infections, falls, medication errors, and pressure ulcers (Blegen,
Goode,Spetz, Vaughn, & Park, 2011; Kane, Shamliyan, Mueller, Duval,
& Wilt, 2007; Lake & Cheung, 2006; Lang, Hodge, Olson, Romano,
& Kravitz, 2004; Lankshear, Sheldon, & Maynard, 2005; Needleman
et al., 2011; Stone et al., 2007; Unruh, 2008). The Agency for
Healthcare Research and Quality (AHRQ) conducted a comprehensive and
systematic review of the 97 observational studies on the relationship
between nurse staffing and patient outcomes published between 1990 and
2006. This AHRQ’s meta-analysis found a strong and consistent
relationship between nurse staffing and specific patient outcomes
(mortality and length of stay), particularly for patients in intensive
care units and surgical units (Kane et al., 2007). For example, length of
stay was shorter by 24% in intensive care units and by 31% in surgical
units as 1 RN per patient day was increased. In addition, nurse
staffing affects care costs. There was evidence that an additional RN
hour per patient day or a 10% increase in the proportion of RNs decreased
the odds of patients’ pneumonia by 8.9% or 9.5%, respectively (Cho,
2003). American Nurses Association (ANA). (2012). ANA’s Principles for
Nurse Staffing, 2nd Edition, Nursebooks.org, Silver Spring, MD. Blegen,
M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011).
Nurse staffing effects on patient outcomes: safety-net and
non-safety-net hospitals. Medical Care, 49(4), 406-414. Cho, S. H.,
Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects
of nurse staffing on adverse events, morbidity, mortality, and medical
costs. Nursing Research, 52(2), 71-79. Elliott, M.N., Kanouse, D.E.,
Edwards, C.A., & Hilborne, L.H. (2009). Components of care vary in
importance for overall patient-reported experience by type of
hospitalization. Medicare Care, (47), 842–849. Institute of Medicine.
(2011). The future of nursing: Leading change, advancing health.
Wahington, D.C.: National Academies Press. Kane, R. L., Shamliyan, T. A.,
Mueller, C., Duval, S., & Wilt, T. J. (2007). The association
of registered nurse staffing levels and patient outcomes: systematic
review and meta-analysis. Medical Care, 45(12), 1195-1204. Kutney-Lee,
A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Neff, D.F.,
Aiken, L.H. (2009). Nursing: a key to patient satisfaction. Health
Affairs, 28(4). Epub 2009 Jun 12. Lake, E. T., & Cheung, R. B.
(2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse
Staffing? Western Journal of Nursing Research, 28(6), 654-677. Lang, T.
A., Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L.
(2004). Nurse-patient ratios: a systematic review on the effects of nurse
staffing on patient, nurse employee, and hospital outcomes. Journal of
Nursing Administration, 34(7-8), 326-337. Lankshear, A. J., Sheldon, T.
A., & Maynard, A. (2005). Nurse staffing and healthcare outcomes: a
systematic review of the international research evidence. Advances in
Nursing Science, 28(2), 163-174. Needleman, J., Buerhaus, P., Pankratz,
V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011).
Nurse staffing and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037-1045. Nursing Alliance for Quality Care (NAQC). (
Measure Specifications
- NQF Number (if applicable): 2104
- Description: Paired Measure: Intensive Care Unit (ICU)
Length-of-Stay (LOS) paired with Intensive Care: In-hospital
mortality rate. E0702 Measure Description: For all patients admitted
to the ICU, total duration of time spent in the ICU until time of
discharge; both observed and risk-adjusted LOS reported with the
predicted LOS measured using the Intensive Care Outcomes Model -
Length-of-Stay (ICOMLOS). E0703 Measure Description: For all adult
patients admitted to the intensive care unit (ICU), the percentage of
patients whose hospital outcome is death; both observed and
risk-adjusted mortality rates are reported with predicted rates based
on the Intensive Care Outcomes Model - Mortality (ICOMmort).[Note:
Measure submitted for endorsement; in process]
- Numerator statement: E0702 Numerator Statement: For all
eligible patients admitted to the ICU, the time at discharge from ICU
(either death or physical departure from the unit) minus the time of
admission (first recorded vital sign on ICU flow sheet) E0703
Numerator Statement: Total number of eligible patients whose hospital
outcome is death
- Denominator statement: E0702 Denominator Statement: Total
number of eligible patients who are discharged (including deaths and
transfers) E0703 Denominator Statement: Total number of eligible
patients who are discharged (including deaths and
transfers)
- Exclusions: E0702 Exclusions: <18 years of age at time
of ICU admission, ICU readmission, <4 hours in ICU, primary
admission due to trauma, burns, or immediately post-CABG, admitted to
exclude myocardial infarction (MI) and subsequently found without MI
or any other acute process requiring ICU care, transfers from another
acute care hospital E0703 Exclusions: <18 years of age at time of
ICU admission, ICU readmission, <4 hours in ICU, primary
admission due to trauma, burns, or immediately post-CABG, admitted to
exclude myocardial infarction (MI) and subsequently found without MI
or any other acute process requiring ICU care, transfers from another
acute care hospital
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Outcome
- Steward: Philip R. Lee Institute for Health Policy
Studies
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
Rationale for measure provided by HHS
Angus DC,
Linde-Zwirble WT, Sirio CA, et al. The effect of managed care on ICU
length of stay: implications for Medicare. JAMA. Oct 2
1996;276(13):1075-1082. Wu AW, Pronovost P, Morlock L. ICU incident
reporting systems. J Crit Care. Jun 2002;17(2):86-94. Young MP, Birkmeyer
JD. Potential reduction in mortality rates using an intensivist model to
manage intensive care units. Eff Clin Pract. Nov-Dec 2000;3(6):284-289.
Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL.
Preventable adverse drug events in hospitalized patients: a comparative
study of intensive care and general care units. Crit Care Med. Aug
1997;25(8):1289-1297. Andrews LB, Stocking C, Krizek T, et al. An
alternative strategy for studying adverse events in medical care. Lancet.
Feb 1 1997;349(9048):309-313. Giraud T, Dhainaut JF, Vaxelaire JF, et al.
Iatrogenic complications in adult intensive care units: a prospective
two-center study. Crit Care Med. Jan 1993;21(1):40-51. Pronovost P, Wu
AW, Dorman T, Morlock L. Building safety into ICU care. J Crit Care. Jun
2002;17(2):78-85. Halpern NA, Pastores SM. Critical care medicine in the
United States 2000-2005: an analysis of bed numbers, occupancy rates,
payer mix, and costs. Crit Care Med. Jan 2010;38(1):65-71. Rapoport J,
Teres D, Lemeshow S, Avrunin JS, Haber R. Explaining variability of cost
using a severity-of-illness measure for ICU patients. Med Care. Apr
1990;28(4):338-348. Rapoport J, Teres D, Lemeshow S, Gehlbach S. A method
for assessing the clinical performance and cost-effectiveness of
intensive care units: a multicenter inception cohort study. Crit Care
Med. Sep 1994;22(9):1385-1391. Gunning K, Rowan K. ABC of intensive care:
outcome data and scoring systems. BMJ. Jul 24 1999;319(7204):241-244.
Shortell SM, Zimmerman JE, Gillies RR, et al. Continuously improving
patient care: practical lessons and an assessment tool from the
National ICU Study. QRB Qual Rev Bull. May 1992;18(5):150-155. Kuzniewicz
MW, Vasilevskis EE, Lane R, et al. Variation in ICU risk-adjusted
mortality: impact of methods of assessment and potential confounders.
Chest. Jun 2008;133(6):1319-1327. Rothen HU, Stricker K, Einfalt J, et
al. Variability in outcome and resource use in intensive care units.
Intensive Care Med. Aug 2007;33(8):1329-1336. Knaus WA, Wagner DP,
Zimmerman JE, Draper EA. Variations in mortality and length of stay in
intensive care units. Ann Intern Med. May 15 1993;118(10):753-761. Render
ML, Kim HM, Deddens J, et al. Variation in outcomes in Veterans
Affairs intensive care units with a computerized severity measure. Crit
Care Med. May 2005;33(5):930-939. Vasilevskis EE, Kuzniewicz MW, Cason
BA, et al. Mortality probability model III and simplified acute
physiology score II: assessing their value in predicting length of stay
and comparison to APACHE IV. Chest. Jul 2009;136(1):89-101. Rosenthal GE,
Harper DL, Quinn LM, Cooper GS. Severity-adjusted mortality and length of
stay in teaching and nonteaching hospitals. Results of a regional study.
JAMA. Aug 13 1997;278(6):485-490. Woods AW, MacKirdy FN, Livingston
BM, Norrie J, Howie JC. Evaluation of predicted and actual length of stay
in 22 Scottish intensive care units using the APACHE III system. Acute
Physiology and Chronic Health Evaluation. Anesthesia. Nov
2000;55(11):1058-1065. Glance LG, Osler TM, Dick AW. Identifying quality
outliers in a large, multiple-institution database by using customized
versions of the Simplified Acute Physiology Score II and the Mortality
Probability Model II0. Crit Care Med. Sep 2002;30(9):1995-2002.
Markgraf R, Deutschinoff G, Pientka L, Scholten T, Lorenz C. Performance
of the score systems Acute Physiology and Chronic Health Evaluation II
and III at an interdisciplinary intensive care unit, after customization.
Crit Care. 2001;5(1):31-36. Murphy-Filkins R, Teres D, Lemeshow S, Hosmer
DW. Effect of changing patient mix on the performance of an intensive
care unit severity-of-illness model: how to
Measure Specifications
- NQF Number (if applicable):
- Description: Participation in a patient safety culture
survey involves a) What is the name of the survey? b) How frequently
is the survey administered? c) Which staff positions complete the
survey? d) Are survey results reported to a centralized location? e)
What is the survey response rate?
- Numerator statement: The facility/hospital conducts a
patient safety culture survey among physicians, nurses, technicians,
and support staff
- Denominator statement: None
- Exclusions: None
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Other (please list in GTL comment
field)
- Measure type: Structure
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP was supportive of including this
structural measure in the IQR program. Workgroup members noted that
participation in a patient safety culture survey is an important
element to building a system of quality improvement within health
care facilities. While some MAP members noted that ideally results of
a patient safety culture survey would be made publiclly available,
the group agreed that there are limitations to reporting the results
of the tools currently used such as the use of two different surveys
that can not be cross-referenced.
- Public comments received: 3
Rationale for measure provided by HHS
A Patient Safety
Culture Survey is TJC element of performance. Making care safer is a
priority for CMS and as such is one of the CMS quality goals. One way to
implement this goal would be to create a patient safety culture
assessment measure. This structural measure will allow us to gain an
understanding of the patient safety culture assessment landscape without
adding undue reporting burden to hospitals. Safety culture surveys are
useful for measuring organizational conditions that can lead to adverse
events and patient harm in healthcare organizations. They can be
used to: ¦raise staff awareness about patient safety ¦diagnose and assess
the current status of patient safety culture ¦identify strengths and
areas for improvement ¦examine trends in patient safety culture and
trends overtime
Measure Specifications
- NQF Number (if applicable): 0141
- Description: All documented falls, with or without injury,
experienced by patients on eligible unit types in a calendar quarter.
Reported as Total Falls per 1,000 Patient Days and Unassisted Falls
per 1000 Patient Days. (Total number of falls / Patient days) X 1000
Measure focus is safety. Target population is adult acute care
inpatient and adult rehabilitation patients.
- Numerator statement: Total number of patient falls (with
or without injury to the patient and whether or not assisted by a
staff member) by hospital unit during the calendar month X 1000.
Target population is adult acute care inpatient and adult
rehabilitation patients. Eligible unit types include adult critical
care, adult step-down, adult medical, adult surgical, adult
medical-surgical combined, critical access, adult rehabilitation
in-patient.
- Denominator statement: Patient days by hospital unit
during the calendar month. Included Populations: •Inpatients, short
stay patients, observation patients, and same day surgery patients
who receive care on eligible inpatient units for all or part of a day
on the following unit types: •Adult critical care, step-down,
medical, surgical, medical-surgical combined, critical access, and
adult rehabilitation units. •Patients of any age on an eligible
reporting unit are included in the patient day count
- Exclusions: Other unit types (e.g., pediatric,
psychiatric, obstetrical, etc.)
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Outcome
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending
applicability at the facility level. MAP conditionally suppoted this
measure pending demonstration of applicability at the facility level.
MAP noted that NQF #0141 and #0202 which are based off clinical data
could provider better information than claims based measure. The MAP
noted that falls are a common adverse event in hospitals, with
estimates of between 2-5 falls per 1,000 patient days. The group
noted that this is an important area for measurement as about 30% of
falls result in injury, disability, or death. Some MAP members
noted concerns that including this self-reported measure in IQR
could lead to underreporting.
- Public comments received: 12
Rationale for measure provided by HHS
The measure focus
addresses several national health goals and priorities, for example: 1.
Recently enacted Centers for Medicare and Medicaid Services regulations
limit hospital reimbursement for care related to fall related injuries.
2. The falls measures fits within the priorities set forth by the
National Priorities Parternship. Specifically, it fits within the
national priority of Making Care Safer (National Priorities Partnership,
2011). 3. As part of their National Patient Safety Goals, The Joint
Commission requires hospitals to reduce the risk of patient harm
resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini,
Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et
al., 2002, 2008). In quarter 3 of 2009, fall rates for nursing units in
participating NDNQI hospitals averaged 3.2 per 1000 patient days
(median = 2.8 per 1000 patient days). About 30% of falls result in injury
disability or death (Shorr, 2008) – particularly in older adults. Injury
falls lead to as much as a 61% increase in patient-care costs and
lengthen a patient’s hospital stay (Fitzpatrick, 2011). Jorgensen (2011)
estimated that by 2020 the direct and indirect costs of injuries related
to falls will reach $54.9 billion. In addition injury falls are a
significant source of liability for hospitals. Agnostini, J.V., Baker,
D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized
and institutionalized older people. In Making health care safer: A
critical analysis of patient safety practices (pp.281-299). Evidence
Report/Technology Assessment Number 43, AHRQ publication No. 01-E058.
Rockville, MD: Agency for Healthcare Research and Quality. Fitzpatrick,
M.A. (2011, March).Meeting the challenge of fall reduction [Supplement].
American Nurse Today, p. 1. Jorgensen, J. (2011, March). Reducing patient
falls: A call to action [Supplement]. American Nurse Today, p.
2-3. National Priorities Partnership. (2011, September). Input to the
Secretary of Health and Human Services on Priorities for the National
Quality Strategy. Retrieved from: http://www.qualityforum.org/Home.aspx
Oliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to
prevent falls and fractures in hospitals and care homes and effect of
cognitive impairment. 384, 82. Shorr, R.I., Guillen, M.k. Rosenblatt,
L.C. (2002). Restraint use, restrain orders, and the risk of falls in
hospitalized patients. Journal of the American Geriatric Society, 50,
526-529. Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving
the capture of fall events in hospitals: Combining a service for
evaluating inpatient falls with an incident report system. Journal of the
American Geriatric Society, 56, 701-704. Unruh, L. (2002). Tends
in adverse events in hospitalized patients. Journal of Healthcare
Quality, 24, 4-10.
Measure Specifications
- NQF Number (if applicable):
- Description: This measure assesses the number of
nulliparous women with a term, singleton baby in a vertex position
who are delivered by a cesarean section. PC O2 is also 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
- Denominator statement: Nulliparous patients delivered of a
live term singleton newborn in vertex presentation
- Exclusions: Excluded Populations: ICD-10-CM Principal
Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple
gestations and other presentations as defined in Appendix A, Table
11.09 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 or UTD
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: EHR
- Measure type: Outcome
- Steward: The Joint Commission
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 4
Rationale for measure provided by HHS
PC O2 is newly
specified for electronic health records. Rationale: The removal of any
pressure to not perform a cesarean birth has led to a skyrocketing of
hospital, state and national cesarean section (CS) rates. Some hospitals
now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant
outcomes that are just as good and better maternal outcomes (Gould et
al., 2004). There are no data that higher rates improve any outcomes,
yet the CS rates continue to rise. This measure seeks to focus attention
on the most variable portion of the CS epidemic, the term labor CS in
nulliparous women. This population segment accounts for the large
majority of the variable portion of the CS rate, and is the area most
affected by subjectivity. As compared to other CS measures, what is
different about NTSV CS rate (Low-risk Primary CS in first births) is
that there are clear cut quality improvement activities that can be done
to address the differences. Main et al. (2006) found that over 60% of the
variation among hospitals can be attributed to first birth labor
induction rates and first birth early labor admission rates. The results
showed if labor was forced when the cervix was not ready the outcomes
were poorer. Alfirevic et al. (2004) also showed that labor and
delivery guidelines can make a difference in labor outcomes. Many authors
have shown that physician factors, rather than patient characteristics or
obstetric diagnoses are the major driver for the difference in rates
within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et
al., 2003). The dramatic variation in NTSV rates seen in all populations
studied is striking according to Menacker (2006). Hospitals within a
state (Coonrod et al., 2008; California Office of Statewide Hospital
Planning and Development [OSHPD], 2007) and physicians within a hospital
(Main, 1999) have rates with a 3-5 fold variation. Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html.
Measure Specifications
- NQF Number (if applicable): 0704
- Description: Percent of adult population aged 18 – 65
years who were admitted to a hospital with acute myocardial
infarction (AMI), were followed for one-month after discharge, and
had one or more potentially avoidable complications (PACs). PACs may
occur during the index stay or during the 30-day post discharge
period. Define PACs during each time period as one of three types:
(A) PACs during the Index Stay (Hospitalization): (1) PACs related to
the anchor condition: The index stay is regarded as having a PAC if
during the index hospitalization the patient develops one or more
complications such as cardiac arrest, ventricular fibrillation,
cardiogenic shock, stroke, coma, acute post-hemorrhagic anemia etc.
that may result directly due to AMI or its management. (2) PACs due
to Comorbidities: The index stay is also regarded as having a
PAC if one or more of the patient’s controlled comorbid conditions is
exacerbated during the hospitalization (i.e. it was not present on
admission). Examples of these PACs are diabetic emergency with hypo-
or hyperglycemia, tracheostomy, mechanical ventilation, pneumonia,
lung complications gastritis, ulcer, GI hemorrhage etc. (3) PACs
suggesting Patient Safety Failures: The index stay is regarded as
having a PAC if there are one or more complications related to
patient safety issues. Examples of these PACs are septicemia,
meningitis, other infections, phlebitis, deep vein thrombosis,
pulmonary embolism or any of the CMS-defined hospital acquired
conditions (HACs). (B) PACs during the 30-day post discharge period:
(1) PACs related to the anchor condition: Readmissions and emergency
room visits during the 30-day post discharge period after an AMI are
considered as PACs if they are for angina, chest pain, another AMI,
stroke, coma, heart failure etc. (2) PACs due to Comorbidities:
Readmissions and emergency room visits during the 30-day post
discharge period are also considered PACs if they are due to an
exacerbation of one or more of the patient’s comorbid conditions,
such as a diabetic emergency with hypo- or hyperglycemia, pneumonia,
lung complications, tracheostomy, mechanical ventilation etc. (3)
PACs suggesting Patient Safety Failures: Readmissions or
emergency room visits during the 30-day post discharge period are
considered PACs if they are due to sepsis, infections, phlebitis,
deep vein thrombosis, or for any of the CMS-defined hospital acquired
conditions (HACs).
- Numerator statement: Outcome: Potentially avoidable
complications (PACs) in patients hospitalized for AMI occurring
during the index stay or in the 30-day post-discharge
period.
- Denominator statement: Adult patients aged 18 – 65 years
who had a relevant hospitalization for AMI (with no exclusions) and
were followed for one-month after discharge
- Exclusions: Denominator exclusions include exclusions of
either “patients” or “claims” based on the following criteria:
(1)“Patients” excluded are those that have any form of cancer, ESRD
(end-stage renal disease), transplants such as lung or heart-lung
transplant or complications related to transplants, pregnancy and
delivery, HIV, or suicide. (2)“Claims” are excluded from the AMI
measure if they are considered not relevant to AMI care or are for
major surgical services that suggests that AMI may be a comorbidity
associated with the procedure e.g. CABG procedure. Patients
where the index hospitalization claim is excluded are automatically
excluded from both the numerator and the denominator.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims, Other (please list
in GTL comment field)
- Measure type: Outcome
- Steward: Bridges to Excellence
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review of the testing data in a Medicare population and resolution of
parsimony concerns with measures currently in the IQR program. ?MAP
was conditionally supported this measure pending expansion of the
measure specifications to greater than 65 years old, and successful
testing and endorsement of the measure with the expanded population.
Currently the measure is specified, tested, and endorsed for 18-65
years old. MAP noted that this measure addresses a number of adverse
outcomes that are meaningful to patients and outcomes that
increase costs across the health care system. The MAP also noted that
this measure extents the idea of measures of all-cause harm which may
be helpful to profile provider performance; however, several members
noted that individual measures of safety events may be more
actionable and relevant to patients selecting providers. Members of
the MAP noted that the NQF Standing Committee should consider the
appropriateness of the avoidable complications that are captured in
the measure. For this measure, MAP debated the extent of the
update to the measure and if it was more appropriate to consider them
through the measures under development pathway. Ultimately, the group
decided to review the measure as a fully developed measure and
conditionally supported its use in the IQR program pending successful
testing and NQF endorsement of the measure with an expanded
population.
- Public comments received: 8
Rationale for measure provided by HHS
High priority aspect
of healthcare: Acute Myocardial Infarction (AMI) is a common cause of
hospitalization and the initial cost of treatment of AMI has been
estimated to begin at approximately $10,000. However, due to considerable
variability in costs of care of typical AMI patients, the average costs
per patient is close to $15,000. Extrapolated to the more than 200,000
Medicare beneficiaries who are annually hospitalized with AMI, the costs
related to initial hospitalizations from AMI could be upwards of $3
billion. Moreover, when AMI admissions incur potentially avoidable
complications, these costs can go up several fold and are truly a waste
within the healthcare system."
Measure Specifications
- NQF Number (if applicable): 0708
- Description: Percent of adult population aged 18 – 65
years who were admitted to a hospital with Pneumonia, were followed
for one-month after discharge, and had one or more potentially
avoidable complications (PACs).[Note: Additional information about
measure description included for endorsed measure in
QPS.]
- Numerator statement: Outcome: Potentially avoidable
complications (PACs) in patients hospitalized for pneumonia occurring
during the index stay or in the 30-day post-discharge
period.
- Denominator statement: Adult patients aged 18 – 65 years
who had a relevant hospitalization for Pneumonia (with no exclusions)
and were followed for one-month after discharge.
- Exclusions: Denominator exclusions include exclusions of
either “patients” or “claims” based on the following criteria:
(1)“Patients” excluded are those that have any form of cancer
(especially cancer of lung and bronchus), thalassemia, sickle-cell
disease, ESRD (end-stage renal disease), transplants such as lung or
heart-lung transplant or complications related to transplants,
pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded
from the Pneumonia measure if they are considered not relevant to
pneumonia care or are for major surgical services that suggests that
pneumonia may be a comorbidity associated with the procedure
e.g. CABG procedure. Patients where the index hospitalization claim
is excluded are automatically excluded from both the numerator and
the denominator.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims, EHR, Other (please
list in GTL comment field)
- Measure type: Outcome
- Steward: Bridges To Excellence
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review of the testing data in a Medicare population and resolution of
parsimony concerns with measures currently in the IQR program. ?MAP
was conditionally supported this measure pending expansion of the
measure specifications to greater than 65 years old, and successful
testing and endorsement of the measure with the expanded population.
Currently the measure is specified, tested, and endorsed for 18-65
years old. MAP noted that this measure addresses a number of adverse
outcomes that are meaningful to patients and outcomes that
increase costs across the health care system. The MAP also noted that
this measure extents the idea of measures of all-cause harm which may
be helpful to profile provider performance; however, several members
noted that individual measures of safety events may be more
actionable and relevant to patients selecting providers. Members of
the MAP noted that the NQF Standing Committee should consider the
appropriateness of the avoidable complications that are captured in
the measure. For this measure, MAP debated the extent of the
update to the measure and if it was more appropriate to consider them
through the measures under development pathway. Ultimately, the group
decided to review the measure as a fully developed measure and
conditionally supported its use in the IQR program pending successful
testing and NQF endorsement of the measure with an expanded
population.
- Public comments received: 8
Rationale for measure provided by HHS
A study from the
Boston Medical Center, Boston MA, demonstrated that although one in five
hospitalizations are complicated by post-discharge adverse events,
development of a strong discharge services program for patients admitted
for medical conditions reduced hospital utilization within 30 days of
discharge. Umscheid et al used 2002 estimates of hospital-acquired
infections (HAI) and determined the range of HAI risk reductions from US
studies. They report that 18%-82% of blood-stream infections, 46%-55% of
ventilator associated pneumonia, 17% - 69% of urinary tract infections
and 26%-54% of surgical site infections are preventable. Healy et al
analyzed complications in hospitalized surgical patients and reported
that between 39% and 61% of major complications (wound infections,
pneumonia, urinary tract infections, arrhythmias, respiratory failure,
gastrointestinal complications, deep vein thrombosis) and about an
equal percent of minor complications could have been avoided. The
National Pressure Ulcer Advisory Panel (NPUAP) reported in 2001 that
pressure ulcer prevention programs had reported 50% or greater reductions
in facility-acquired pressure ulcers. Similarly, appropriate prophylaxis
could reduce the risk of venous thromboembolism by 45% in acutely ill
medical patients, and a recent study found a 50% reduction in
thromboembolic events with extended pharmacologic prophylaxis. Adequate
evidence-based treatment protocols in preventing contrast
nephropathy and adequate drug dosing have demonstrated a risk reduction
between 52% and 90% in the incidence of acute renal failure in patients
in the intensive care unit. Additionally, use of electronic medical
systems has demonstrated that in a sample hospital that used prompts for
protocols for nursing care, infection rates dropped 88%, bedsores were
reduced and compliance to guidelines for care of patients on ventilator
increased by 77%.
Measure Specifications
- NQF Number (if applicable): 0705
- Description: Percent of adult population aged 18 – 65
years who were admitted to a hospital with stroke, were followed for
one-month after discharge, and had one or more potentially avoidable
complications (PACs). PACs may occur during the index stay or during
the 30-day post discharge period. Define PACs during each time period
as one of three types: (A) PACs during the Index Stay
(Hospitalization): (1) PACs related to the anchor condition: The
index stay is regarded as having a PAC if during the index
hospitalization for stroke the patient develops one or more
complications such as hypertensive encephalopathy, malignant
hypertension, coma, anoxic brain damage, or respiratory failure etc.
that may result directly from stroke or its management. (2) PACs due
to Comorbidities: The index stay is also regarded as having a PAC
if one or more of the patient’s controlled comorbid conditions
is exacerbated during the hospitalization (i.e. it was not present on
admission). Examples of these PACs are diabetic emergency with hypo-
or hyperglycemia, pneumonia, lung complications, acute myocardial
infarction, gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting
Patient Safety Failures: The index stay is regarded as having a PAC
if there are one or more complications related to patient safety
issues. Examples of these PACs are septicemia, meningitis, other
infections, phlebitis, deep vein thrombosis, pulmonary embolism or
any of the CMS-defined hospital acquired conditions (HACs). (B) PACs
during the 30-day post discharge period: (1) PACs related to the
anchor condition: Readmissions and emergency room visits during the
30-day post discharge period after a stroke are considered as PACs if
they are for hypertensive encephalopathy, malignant hypertension,
respiratory failure, coma, anoxic brain damage etc. (2) PACs due
to Comorbidities: Readmissions and emergency room visits during the
30-day post discharge period are also considered PACs if they are due
to an exacerbation of one or more of the patient’s comorbid
conditions, such as a diabetic emergency with hypo- or hyperglycemia,
pneumonia, lung complications, acute myocardial infarction, acute
renal failure etc. (3) PACs suggesting Patient Safety Failures:
Readmissions or emergency room visits during the 30-day post
discharge period are considered PACs if they are due to sepsis,
infections, deep vein thrombosis, pulmonary embolism, or for any of
the CMS-defined hospital acquired conditions (HACs).
- Numerator statement: Outcome: Potentially avoidable
complications (PACs) in patients hospitalized for stroke occurring
during the index stay or in the 30-day post-discharge
period.
- Denominator statement: Adult patients aged 18 – 65 years
who had a relevant hospitalization for stroke (with no exclusions)
and were followed for one-month after discharge.
- Exclusions: Denominator exclusions include exclusions of
either “patients” or “claims” based on the following criteria:
(1)“Patients” excluded are those with that have any form of cancer,
ESRD (end-stage renal disease), transplants such as lung or
heart-lung transplant or complications related to transplants,
intracranial trauma, pregnancy and delivery, HIV, or suicide.
(2)“Claims” are excluded from the stroke measure if they are
considered not relevant to stroke care or are for major surgical
services that suggests that stroke may be a comorbidity or
complication associated with the procedure e.g. CABG procedure.
Patients where the index hospitalization claim is excluded are
automatically excluded from both the numerator and the
denominator.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims, EHR
- Measure type: Outcome
- Steward: Bridges to Excellence
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review of the testing data in a Medicare population and resolution of
parsimony concerns with measures currently in the IQR program. ?MAP
was conditionally supported this measure pending expansion of the
measure specifications to greater than 65 years old, and successful
testing and endorsement of the measure with the expanded population.
Currently the measure is specified, tested, and endorsed for 18-65
years old. MAP noted that this measure addresses a number of adverse
outcomes that are meaningful to patients and outcomes that
increase costs across the health care system. The MAP also noted that
this measure extents the idea of measures of all-cause harm which may
be helpful to profile provider performance; however, several members
noted that individual measures of safety events may be more
actionable and relevant to patients selecting providers. Members of
the MAP noted that the NQF Standing Committee should consider the
appropriateness of the avoidable complications that are captured in
the measure. For this measure, MAP debated the extent of the
update to the measure and if it was more appropriate to consider them
through the measures under development pathway. Ultimately, the group
decided to review the measure as a fully developed measure and
conditionally supported its use in the IQR program pending successful
testing and NQF endorsement of the measure with an expanded
population.
- Public comments received: 9
Rationale for measure provided by HHS
Hospital acquired
conditions (HACs) have been defined by the Centers for Medicare and
Medicaid (CMS) under the proposed rules for 2008 and 2009 and are
avoidable conditions in hospitalized patients. Our potentially avoidable
complications (PACs) go beyond the CMS defined HACs and identify
conditions related to the index condition, to comorbidities that got
exacerbated, as well as those related to patient safety failures. While
there is a general understanding of the nature of care failures during
hospitalizations or post-discharge such as readmissions and emergency
room visits, there has been no attempt to measure the magnitude or the
type of potentially avoidable complications, and the cost reductions that
would ensue if a payment model encouraged care to be optimized at
benchmarks achieved in studies. Well-managed patients with stroke should
rarely incur a potentially avoidable complication such as an emergency
room visit post-discharge, and readmissions related to stroke should
occur only in the rarest of circumstances. The enclosed workbook
entitled NQF_Stroke_PACs_Risk_Adjustment 2.16.10.xls lists the types of
PACs, their frequency and costs as calculated in our national database,
for both the inpatient stays and readmissions (see tabs
CIP_Index_PAC_Stays and CIP_PAC_Readmissions). The PAC Overview tab shows
that 57.8% of all hospitalizations for stroke had a PAC, with 53% of
index stays having a PAC during the initial hospitalization. Of these
PACs, over 18.5% were incurred for direct complications of stroke,
another 47% for acute exacerbation of a comorbidity, and another 34.4%
due to patient safety failures such as sepsis and other widespread
infections, complications of surgical procedures, phlebitis and deep vein
thrombosis or CMS-defined hospital acquired conditions. The
primary cause for readmissions and emergency room visits during the
30-day post-discharge period was due to a hypertensive encephalopathy,
diabetic emergency with hypo- or hyperglycemia, pneumonia or lung
complications, or patient safety failures such as skin or wound
infections or sepsis. The ability to clearly identify the type and
frequency of each PAC creates a highly actionable measure for all
providers that are managing or co-managing the patient, as well as for
the health plan with whom the patient is a member.
Measure Specifications
- NQF Number (if applicable): 0204
- Description: NSC-12.1 - Percentage of total productive
nursing hours worked by RN (employee and contract) with direct
patient care responsibilities by hospital unit. NSC-12.2 - Percentage
of total productive nursing hours worked by LPN/LVN (employee and
contract) with direct patient care responsibilities by hospital unit.
NSC-12.3 - Percentage of total productive nursing hours worked by UAP
(employee and contract) with direct patient care responsibilities by
hospital unit. NSC-12.4 - Percentage of total productive
nursing hours worked by contract or agency staff (RN, LPN/LVN, and
UAP) with direct patient care responsibilities by hospital unit. Note
that the skill mix of the nursing staff (NSC-12.1, NSC-12.2, and
NSC-12.3) represent the proportions of total productive nursing hours
by each type of nursing staff (RN, LPN/LVN, and UAP); NSC-12.4 is a
separate rate. Measure focus is structure of care quality in acute
care hospital units.
- Numerator statement: Four separate numerators are as
follows: RN hours – Productive nursing care hours worked by RNs with
direct patient care responsibilities for each hospital in-patient
unit during the calendar month. LPN/LVN hours – Productive nursing
care hours worked by LPNs/LVNs with direct patient care
responsibilities for each hospital in-patient unit during the
calendar month. UAP hours – Productive nursing care hours worked by
UAP with direct patient care responsibilities for each hospital
in-patient unit during the calendar month. Contract or agency hours –
Productive nursing care hours worked by nursing staff
(contract or agency staff) with direct patient care responsibilities
for each hospital in-patient unit during the calendar
month.
- Denominator statement: Denominator is the total number of
productive hours worked by employee or contract nursing staff with
direct patient care responsibilities (RN, LPN/LVN, and UAP) for each
hospital in-patient unit during the calendar month.
- Exclusions: Same as numerator; nursing staff with no
direct patient care responsibilities are excluded. Excluded nursing
staff: Persons whose primary responsibility is administrative in
nature. Specialty teams, patient educators, or case managers who are
not assigned to a specific unit. Unit secretaries or clerks, monitor
technicians, and other with no direct patient care
responsibilities.[For reference, exclusions for NQF endorsed measure
from QPS: Same as numerator; nursing staff with no direct patient
care responsibilities are excluded.]
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Administrative Claims, Administrative
Clinical Data, Hybrid, Other (please list in GTL comment
field)
- Measure type: Structure
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
review and endorsement of this measure at the facility level. MAP was
conditionally supportive of this measure pending NQF review and
endorsement of this measure at the facility level. Additionally, MAP
noted the need for resolution of data issues, specifically that
hospitals participating in the NDNQI program can have their data
directly shared with CMS while those that do not currently
participate in that program have the opportunity to send their data
directly to CMS. Some members noted that there is no gold standard
for this measure and thus it is difficult to access relative
performance on this measure.
- Public comments received: 16
Rationale for measure provided by HHS
With the increasing
concerns about cost and quality of patient care over the past 2 decades,
hospital nurse staffing has become a major focus in examining health care
workforce relationships with patient outcomes. Nurses are the largest
group of clinical providers of care in healthcare systems. The Institute
of Medicine recently concluded, in its report, The Future of
Nursing: Leading Changing, Advancing Health (2010), that nurses are vital
in providing quality care to patients. A large body of research has
demonstrated that higher nurse staffing levels are significantly
associated with better patient outcomes, including shorter length of stay
and lower rates of mortality, failure to rescue, hospital acquired
infections, falls, medication errors, and pressure ulcers (Blegen,
Goode,Spetz, Vaughn, & Park, 2011; Kane, Shamliyan, Mueller, Duval,
& Wilt, 2007; Lake & Cheung, 2006; Lang, Hodge, Olson, Romano,
& Kravitz, 2004; Lankshear, Sheldon, & Maynard, 2005; Needleman
et al., 2011; Stone et al., 2007; Unruh, 2008). The Agency for
Healthcare Research and Quality (AHRQ) conducted a comprehensive and
systematic review of the 97 observational studies on the relationship
between nurse staffing and patient outcomes published between 1990 and
2006. This AHRQ’s meta-analysis found a strong and consistent
relationship between nurse staffing and specific patient outcomes
(mortality and length of stay), particularly for patients in intensive
care units and surgical units (Kane et al., 2007). For example, length of
stay was shorter by 24% in intensive care units and by 31% in surgical
units as 1 RN per patient day was increased. In addition, nurse
staffing affects care costs. There was evidence that an additional RN
hour per patient day or a 10% increase in the proportion of RNs decreased
the odds of patients’ pneumonia by 8.9% or 9.5%, respectively (Cho,
2003). American Nurses Association (ANA). (2012). ANA’s Principles for
Nurse Staffing, 2nd Edition, Nursebooks.org, Silver Spring, MD. Blegen,
M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011).
Nurse staffing effects on patient outcomes: safety-net and
non-safety-net hospitals. Medical Care, 49(4), 406-414. Cho, S. H.,
Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects
of nurse staffing on adverse events, morbidity, mortality, and medical
costs. Nursing Research, 52(2), 71-79. Elliott, M.N., Kanouse, D.E.,
Edwards, C.A., & Hilborne, L.H. (2009). Components of care vary in
importance for overall patient-reported experience by type of
hospitalization. Medicare Care, (47), 842–849. Institute of Medicine.
(2011). The future of nursing: Leading change, advancing health.
Wahington, D.C.: National Academies Press. Kane, R. L., Shamliyan, T. A.,
Mueller, C., Duval, S., & Wilt, T. J. (2007). The association
of registered nurse staffing levels and patient outcomes: systematic
review and meta-analysis. Medical Care, 45(12), 1195-1204. Kutney-Lee,
A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Neff, D.F.,
Aiken, L.H. (2009). Nursing: a key to patient satisfaction. Health
Affairs, 28(4). Epub 2009 Jun 12. Lake, E. T., & Cheung, R. B.
(2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse
Staffing? Western Journal of Nursing Research, 28(6), 654-677. Lang, T.
A., Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L.
(2004). Nurse-patient ratios: a systematic review on the effects of nurse
staffing on patient, nurse employee, and hospital outcomes. Journal of
Nursing Administration, 34(7-8), 326-337. Lankshear, A. J., Sheldon, T.
A., & Maynard, A. (2005). Nurse staffing and healthcare outcomes: a
systematic review of the international research evidence. Advances in
Nursing Science, 28(2), 163-174. Needleman, J., Buerhaus, P., Pankratz,
V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011).
Nurse staffing and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037-1045. Nursing Alliance for Quality Care (NAQC). (
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending NQF review and endorsement. Some members raised
concerns that patients with cancer should be excluded from this
measure. The relevant NQF Standing Committee should consider these
issues in its review of these measures for endorsement.?
- Public comments received: 6
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)).
Measure Specifications
- NQF Number (if applicable):
- Description: Median time from emergency department (ED)
arrival to provider evaluation for individuals triaged at the two
highest levels based on a five-level triage system (e.g., triaged as
“immediate” or “emergent”).
- Numerator statement: Measure Observation 1: Median time
(in minutes) from ED arrival to Qualified Provider Contact for
Emergency Department patients triaged with an acuity level of
"1-immediate". Measure Observation 2: Median time (in minutes) from
ED arrival to Qualified Provider Contact for Emergency Department
patients triaged with an acuity level of "2-emergent".
- Denominator statement: Measure Population: Any emergency
department encounter for which individuals with a triage score of
“1-Immediate” or "2-Emergent" based on a 5-level triage
system.
- Exclusions: ED visit for trauma
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP has previously stressed the
importance of ED throughput measures as important markers of
efficiency and safety which can dramatically impact patient
experience.This measure in particular would address severely ill
patients being admitted to the ED. The MAP encouraged continued
development of this e-measure it may have the potential to capture
important clinical data.
- Public comments received: 2
Rationale for measure provided by HHS
This is a new eCQM
that assesses a different aspect of ED provider care, and specifically
assesses provider timeliness to evaluation. The anticipated effect of
implementing this measure would be to reduce the time for high risk
patients to be seen by a physician in the emergency department and
thereby reduce adverse events (i.e., morbidity and mortality). High-risk
individuals are identified by assignment of the highest or most
urgent score from a valid triage system.
Measure Specifications
- NQF Number (if applicable): 0349
- Description: The count of medical and surgical discharges
for patients age greater than or equal to 18 or in MDC 14 with
ICD-9-CM code for transfusion reaction in any secondary diagnosis
field.
- Numerator statement: Discharges 18 years and older or in
MDC 14 with ICD-9-CM codes for transfusion reaction in any secondary
diagnosis field of all medical and surgical discharges defined by
specific DRGs or MS-DRGs[For reference, additional information
included in numerator for NQF endorsed measure in QPS: See Patient
Safety Indicators Appendices:- Appendix B – Medical Discharge DRGs -
Appendix C – Medical Discharge MS-DRGs - Appendix D – Surgical
Discharge DRGs- Appendix E – Surgical Discharge MS-DRGsLink to PSI
appendices:
http://qualityindicators.ahrq.gov/Downloads/Software/SAS/V43/TechnicalSpecifications/PSI%20Appendices.pdf
Exclude cases:-with principal diagnosis of transfusion
reaction or secondary diagnosis present on admission-with missing
gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year
(YEAR=missing) or principal diagnosis (DX1=missing)]
- Denominator statement: N/A
- Exclusions: None
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Agency for Healthcare Research & Quality
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 0
Rationale for measure provided by HHS
Transfusion reaction
is a health outcome measure. This measure captures illness or injury
resulting from administration of mismatched blood or blood products,
based on ABO or Rh antigens. These events are considered to be almost
entirely preventable. For example, the 2011 Update of the NQF Serious
Reportable Events in Healthcare includes this specification of “Patient
death or serious injury associated with unsafe administration of
blood products”: “Unsafe administration includes, but is not limited to
hemolytic reactions and administering a) blood or blood products to the
wrong patient; b) the wrong type; or c) blood or blood products that have
been improperly stored or handled.” Similarly, “Hemolytic transfusion
reaction involving administration of blood or blood products having major
blood group incompatibilities” is classified as a sentinel event by
The Joint Commission. Preoperative evaluation of a patient for blood
transfusion includes (1) reviewing previous medical records, (2)
conducting a patient or family interview, and (3) reviewing laboratory
test results. American Society of Anesthesiologists Task Force on
Perioperative Blood Transfusion and Adjuvant Therapies. Practice
guidelines for perioperative blood transfusion and adjuvant therapies: an
updated report by the American Society of Anesthesiologists Task Force on
Perioperative Blood Transfusion and Adjuvant Therapies.
Anesthesiology. 2006 Jul;105(1):198-208. According to one recent review
(Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical outcomes of
ABO-incompatible RBC transfusions. Am J Clin Pathol 2008; 129(2):276-81),
“the most frequent error leading to transfusion of ABO-incompatible blood
is failure of the final patient identification check at the bedside,
leading to transfusion of properly labeled blood to a recipient other
than the one intended. In a recent report from Ireland´s
hemovigilance system, more than half of all adverse reactions to blood
transfusion were caused by the patient being given the wrong blood
component. The relative distribution of errors in our cases and survey
results are similar to those in other reports, with failures in
pretransfusion verification of patient identification comprising a
majority of all errors, followed by laboratory errors, and errors in
sample collection and labeling… With an increased awareness of the root
causes of transfusion errors, hospitals have taken steps to address them,
such as requiring 2 pre-transfusion samples to confirm a patient´s
initial ABO blood type result (independent of the American Association of
Blood Banks standard requiring 2 determinations of the recipient´s ABO
type if using computer crossmatching). In theory, requiring a second
sample to confirm the ABO blood type could significantly reduce
ABO-incompatible transfusion because the vast majority of errors are due
to sample collection and labeling and bedside errors. A reduction in the
use of stationary refrigerators in the operating room is reported to
have reduced some transfusion errors… Various devices have also been
introduced to minimize errors in sample collection and transfusion to the
intended recipient and have prevented some errors. These are summarized
in a recent review. However, it is difficult to know whether actual use
of these devices is widespread and their effectiveness in preventing
ABO-incompatible transfusions…. Quality improvement dictates that
analysis of adverse sentinel events such as ABO-incompatible transfusions
be performed. When such an event has been identified, corrective measures
should be instituted to prevent recurrences.
Measure Specifications
- NQF Number (if applicable): 2634
- Description: This quality measure estimates the average
risk-adjusted mean change in mobility function between admission and
discharge for patients discharged from an IRF.
- Numerator statement: The mean change in mobility
function.
- Denominator statement: Patients discharged from the
IRF.
- Exclusions: Three exclusion criteria apply to the change
in mobility function score quality measure: 1) Patients with
incomplete stays: It can be challenging to gather accurate discharge
functional status data for patients who experience incomplete stays.
Patients with incomplete stays include patients who are unexpectedly
discharged to an acute care setting (IPPS, CAH, IPF, or LTCH) due to
a medical emergency; patients who die or leave an IRF against medical
advice; and patients with a length of stay less than 3 days.
2) Patients who are independent with CARE mobility activities at the
time of admission: Patients who are independent with the CARE
mobility items at the time of admission are assigned the highest
score on all the mobility items, and thus, would not be able to show
functional improvement on this same set of items at discharge. 3)
Patients younger than age 21.
- HHS NQS Priority: Patient and Family Engagement,
Communication and Care Coordination
- HHS Data Source: Other (please list in GTL comment
field)
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP conditionally supported four functional outcome
measures under consideration for this program. MAP recognized this
measure would be meaningful to consumers and would help promote
clarity, consumer engagement, and alignment across settings. MAP
members noted this measure is actionable and has an opportunity for
improvement. However, some MAP members questioned that these measures
may be redundant with each other and with information currently
collected from the Inpatient Rehabilitation Facility Patient
Assessment (IRF-PAI). However, MAP ultimately concluded that the two
different types of measures under consideration will present a
more thorough picture of a patient’s progression over the course of
their rehab as well as the important change from admission to
discharge. MAP raised concerns regarding the potential duplicity
between the CARE tool and the IRF-PAI recognizing the potential
burden of maintaining data on two scales. MAP recommended
coordinating the scales to maintain staff competency and the quality
of the data generated.
- Public comments received: 10
Rationale for measure provided by HHS
Given that the
primary goal of rehabilitation is improvement in function, IRF clinicians
have traditionally assessed and documented patients’ functional status at
admission and discharge to evaluate the effectiveness of the
rehabilitation care provided to individual patients, as well as the
effectiveness of the rehabilitation unit or hospital overall. Studies
have shown differences in IRF patients’ functional outcomes by geographic
region, insurance type, and race/ethnicity after adjusting for key
patient demographic characteristics and admission clinical status, which
supports the need to monitor IRF patients’ functional outcomes.
Measure Specifications
- NQF Number (if applicable): 2633
- Description: This measure estimates the average
risk-adjusted mean change in self-care function between admission and
discharge for patients discharged from IRFs.
- Numerator statement: The mean change in self-care
function.
- Denominator statement: Patients discharged from the
IRF.
- Exclusions: Four exclusion criteria apply to the change in
self-care function score measure: 1) Patients with incomplete stays:
It can be challenging to gather accurate discharge functional status
data for patients who experience incomplete stays. Patients with
incomplete stays include patients who are unexpectedly discharged to
an acute-care setting (Inpatient Prospective Payment System, Critical
Access Hospital, Inpatient Psychiatric Hospital, or LTCH) due to a
medical emergency; patients who die; patients who leave an IRF
against medical advice; and patients with a length of stay less than
3 days. 2) Patients who are independent with CARE self-care
activities at the time of admission: Patients who are independent
with the CARE self-care items at the time of admission are assigned
the highest score on all the self-care items, and thus, would not be
able to show functional improvement on this same set of items at
discharge. 3) Patients in coma, persistent vegetative state, complete
teraplegia, and locked-in syndrome are excluded, because they
may have limited or less predictable self-care improvement. 4)
Patients younger than age 21.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Other
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP conditionally supported four functional outcome
measures under consideration for this program. MAP recognized this
measure would be meaningful to consumers and would help promote
clarity, consumer engagement, and alignment across settings. MAP
members noted this measure is actionable and has an opportunity for
improvement. However, some MAP members questioned that these measures
may be redundant with each other and with information currently
collected from the Inpatient Rehabilitation Facility Patient
Assessment (IRF-PAI). However, MAP ultimately concluded that the two
different types of measures under consideration will present a
more thorough picture of a patient’s progression over the course of
their rehab as well as the important change from admission to
discharge. MAP raised concerns regarding the potential duplicity
between the CARE tool and the IRF-PAI recognizing the potential
burden of maintaining data on two scales. MAP recommended
coordinating the scales to maintain staff competency and the quality
of the data generated.
- Public comments received: 13
Rationale for measure provided by HHS
Given that the
primary goal of rehabilitation is improvement in functional status, IRF
clinicians have traditionally assessed and documented patients’
functional status at admission and at discharge to evaluate the
effectiveness of the rehabilitation care provided to individual patients,
as well as the effectiveness of the rehabilitation unit or hospital
overall. Studies have shown differences in IRF patients’ functional
outcomes by geographic region, insurance type, and race/ethnicity after
adjusting for key patient demographic characteristics and admission
clinical status, which supports the need to monitor IRF patients’
functional outcomes.
Measure Specifications
- NQF Number (if applicable): 2636
- Description: This measure calculates the percent of
patients who meet or exceed an expected discharge mobility
score.
- Numerator statement: The number of patients who meet or
exceed an expected discharge mobility score.
- Denominator statement: Patients discharged during the
selected time period.
- Exclusions: Two exclusion criteria apply to the discharge
mobility function score measure: 1) Patients with incomplete stays:
It can be challenging to gather accurate discharge functional status
data for patients who experience incomplete stays. Patients with
incomplete stays include patients who are unexpectedly discharged to
an acute-care setting (IPPS, CAH, or LTCH) due to a medical
emergency; patients who die or leave an IRF against medical advice;
and patients with a length of stay less than 3 days. 2) Patients
younger than age 21.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Other
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP conditionally supported four functional outcome
measures under consideration for this program. MAP recognized this
measure would be meaningful to consumers and would help promote
clarity, consumer engagement, and alignment across settings. MAP
members noted this measure is actionable and has an opportunity for
improvement. However, some MAP members questioned that these measures
may be redundant with each other and with information currently
collected from the Inpatient Rehabilitation Facility Patient
Assessment (IRF-PAI). However, MAP ultimately concluded that the two
different types of measures under consideration will present a
more thorough picture of a patient’s progression over the course of
their rehab as well as the important change from admission to
discharge. MAP raised concerns regarding the potential duplicity
between the CARE tool and the IRF-PAI recognizing the potential
burden of maintaining data on two scales. MAP recommended
coordinating the scales to maintain staff competency and the quality
of the data generated.
- Public comments received: 11
Rationale for measure provided by HHS
Given that the
primary goal of rehabilitation is improvement in function, IRF clinicians
have traditionally assessed and documented patients’ functional status at
admission and at discharge to evaluate the effectiveness of the
rehabilitation care provided to individual patients, as well as the
effectiveness of the rehabilitation unit or hospital overall. Studies
have shown differences in IRF patients’ functional outcomes by geographic
region, insurance type, and race/ethnicity after adjusting for key
patient demographic characteristics and admission clinical status, which
supports the need to monitor IRF patients’ functional outcomes.
Measure Specifications
- NQF Number (if applicable): 2635
- Description: This quality measure calculates the percent
of patients who meet or exceed an expected discharge self-care score
in IRFs.
- Numerator statement: The number of patients who meet or
exceed an expected discharge self-care score.
- Denominator statement: Patients discharged during the
selected time period.
- Exclusions: Two exclusion criteria apply to the discharge
in self-care function quality measure: 1) Patients with incomplete
stays: It can be challenging to gather accurate discharge functional
status data for patients who experience incomplete stays. Patients
with incomplete stays include patients who are unexpectedly
discharged to an acute-care setting (IPPS, CAH, IPF, or LTCH) due to
a medical emergency; patients who die or leave an IRF against medical
advice; and patients with a length of stay less than 3 days.
2) Patients younger than age 21.
- HHS NQS Priority: Patient and Family Engagement,
Communication and Care Coordination
- HHS Data Source: Other
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. MAP conditionally supported four functional outcome
measures under consideration for this program. MAP recognized this
measure would be meaningful to consumers and would help promote
clarity, consumer engagement, and alignment across settings. MAP
members noted this measure is actionable and has an opportunity for
improvement. However, some MAP members questioned that these measures
may be redundant with each other and with information currently
collected from the Inpatient Rehabilitation Facility Patient
Assessment (IRF-PAI). However, MAP ultimately concluded that the two
different types of measures under consideration will present a
more thorough picture of a patient’s progression over the course of
their rehab as well as the important change from admission to
discharge. MAP raised concerns regarding the potential duplicity
between the CARE tool and the IRF-PAI recognizing the potential
burden of maintaining data on two scales. MAP recommended
coordinating the scales to maintain staff competency and the quality
of the data generated.
- Public comments received: 10
Rationale for measure provided by HHS
Given that the
primary goal of rehabilitation is improvement in functional status, IRF
clinicians have traditionally assessed and documented patients’
functional status at admission and at discharge to evaluate the
effectiveness of the rehabilitation care provided to individual patients,
as well as the effectiveness of the rehabilitation unit or hospital
overall. Studies have shown differences in IRF patients’ functional
outcomes by geographic region, insurance type, and race/ethnicity after
adjusting for key patient demographic characteristics and admission
clinical status, which supports the need to monitor IRF patients’
functional outcomes.
| Patient fall rate
(Program: Inpatient Rehabilitation Facilities Quality
Reporting Program; MUC ID: E0141) |
Measure Specifications
- NQF Number (if applicable): 0141
- Description: All documented falls, with or without injury,
experienced by patients on eligible unit types in a calendar quarter.
Reported as Total Falls per 1,000 Patient Days and Unassisted Falls
per 1000 Patient Days. (Total number of falls / Patient days) X 1000
Measure focus is safety. Target population is adult acute care
inpatient and adult rehabilitation patients.
- Numerator statement: Total number of patient falls (with
or without injury to the patient and whether or not assisted by a
staff member) by hospital unit during the calendar month X 1000.
Target population is adult acute care inpatient and adult
rehabilitation patients. Eligible unit types include adult critical
care, adult step-down, adult medical, adult surgical, adult
medical-surgical combined, critical access, adult rehabilitation
in-patient.
- Denominator statement: Patient days by hospital unit
during the calendar month. Included Populations: •Inpatients, short
stay patients, observation patients, and same day surgery patients
who receive care on eligible inpatient units for all or part of a day
on the following unit types: •Adult critical care, step-down,
medical, surgical, medical-surgical combined, critical access, and
adult rehabilitation units. •Patients of any age on an eligible
reporting unit are included in the patient day count
- Exclusions: Other unit types (e.g., pediatric,
psychiatric, obstetrical, etc.)
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Outcome
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 9
Rationale for measure provided by HHS
The measure focus
addresses several national health goals and priorities, for example: 1.
Recently enacted Centers for Medicare and Medicaid Services regulations
limit hospital reimbursement for care related to fall related injuries.
2. The falls measures fits within the priorities set forth by the
National Priorities Parternship. Specifically, it fits within the
national priority of Making Care Safer (National Priorities Partnership,
2011). 3. As part of their National Patient Safety Goals, The Joint
Commission requires hospitals to reduce the risk of patient harm
resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini,
Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et
al., 2002, 2008). In quarter 3 of 2009, fall rates for nursing units in
participating NDNQI hospitals averaged 3.2 per 1000 patient days
(median = 2.8 per 1000 patient days). About 30% of falls result in injury
disability or death (Shorr, 2008) – particularly in older adults. Injury
falls lead to as much as a 61% increase in patient-care costs and
lengthen a patient’s hospital stay (Fitzpatrick, 2011). Jorgensen (2011)
estimated that by 2020 the direct and indirect costs of injuries related
to falls will reach $54.9 billion. In addition injury falls are a
significant source of liability for hospitals. Agnostini, J.V., Baker,
D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized
and institutionalized older people. In Making health care safer: A
critical analysis of patient safety practices (pp.281-299). Evidence
Report/Technology Assessment Number 43, AHRQ publication No. 01-E058.
Rockville, MD: Agency for Healthcare Research and Quality. Fitzpatrick,
M.A. (2011, March).Meeting the challenge of fall reduction [Supplement].
American Nurse Today, p. 1. Jorgensen, J. (2011, March). Reducing patient
falls: A call to action [Supplement]. American Nurse Today, p.
2-3. National Priorities Partnership. (2011, September). Input to the
Secretary of Health and Human Services on Priorities for the National
Quality Strategy. Retrieved from: http://www.qualityforum.org/Home.aspx
Oliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to
prevent falls and fractures in hospitals and care homes and effect of
cognitive impairment. 384, 82. Shorr, R.I., Guillen, M.k. Rosenblatt,
L.C. (2002). Restraint use, restrain orders, and the risk of falls in
hospitalized patients. Journal of the American Geriatric Society, 50,
526-529. Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving
the capture of fall events in hospitals: Combining a service for
evaluating inpatient falls with an incident report system. Journal of the
American Geriatric Society, 56, 701-704. Unruh, L. (2002). Tends
in adverse events in hospitalized patients. Journal of Healthcare
Quality, 24, 4-10.
Measure Specifications
- NQF Number (if applicable): 0371
- Description: This measure assesses the number of patients
who received venous thromboembolism (VTE) prophylaxis or have
documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start
the day of or the day after hospital admission. This measure is part
of a set of six nationally implemented prevention and treatment
measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE
Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients
Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE
Warfarin Therapy Discharge Instructions and VTE-6: Hospital
Acquired Potentially-Preventable VTE) that are used in The Joint
Commission’s accreditation process.
- Numerator statement: Patients who received VTE prophylaxis
or have documentation why no VTE prophylaxis was given: • the day of
or the day after hospital admission • the day of or the day after
surgery end date for surgeries that start the day of or the day after
hospital admission
- Denominator statement: All discharged hospital
inpatients
- Exclusions: Patients less than 18 years of age • Patients
who have a length of stay (LOS) less than two days and greater than
120 days • Patients with Comfort Measures Only documented on day of
or day after hospital arrival • Patients enrolled in clinical trials
related to VTE • Patients who are direct admits to intensive care
unit (ICU), or transferred to ICU the day of or the day after
hospital admission with ICU LOS greater than or equal to one day •
Patients with ICD-9-CM Principal Diagnosis Code of Mental
Disorders or Stroke as defined in Appendix A, Table 7.01, 8.1 or 8.2
• Patients with ICD-9-CM Principal or Other Diagnosis Codes of
Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03 or 7.04
• Patients with ICD-9-CM Principal Procedure Code of Surgical Care
Improvement Project (SCIP) VTE selected surgeries as defined in
Appendix A, Tables 5.17, 5.19, 5.20, 5.21, 5.22, 5.23,
5.24
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Process
- Steward: The Joint Commission
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending updates
to expand the setting for IRFs and NQF endorsement of the expanded
measure. MAP members noted concerns about the exclusions for stroke
patients and patients with stays longer than 120 days. MAP encouraged
the relevant NQF Standing Committee to consider this issue in its
review of this measure for endorsement maintenance.
- Public comments received: 10
Rationale for measure provided by HHS
The estimated annual
incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE),
known collectively as venous thromboembolism (VTE), is approximately
900,000 cases. Of these, approximately one third of the cases (300,000)
are fatal PE, and the remaining two-thirds are non-fatal episodes of DVT
or PE. The majority of fatal events occur as sudden or abrupt death,
underscoring the importance of prevention as the most critical action
step for reducing death from PE. Of the estimated 600,000 cases of
non-fatal venous thromboembolism each year, about 60% are cases of DVT,
and 40% are episodes PE. Among patients who present with symptomatic DVT
as the chief presenting complaint, 50% or more have evidence of pulmonary
embolism (mostly asymptomatic) by diagnostic imaging procedures such as
radionuclide lung scanning or CT imaging .The incidence of venous
thromboembolism increases markedly in patients of age 60 years or more.
Approximately two-thirds of cases of DVT or PE are associated with recent
hospitalization. This is consistent with the 2001 report by The Agency
for Healthcare Research and Quality (AHRQ). AHRQ indicates that “the
appropriate application of effective preventive measures in hospitals has
major potential for improving patient safety by reducing the incidence
of venous thromboembolism.” Although the majority of cases of DVT and
PE are associated with recent hospitalization, many of the patients
present clinically after hospital discharge, because the length of stay
for most surgeries and medical conditions has been markedly reduced in
recent years. The aging of the United States population, the more
extensive use of surgical procedures in older patients, and multiple
hospital admissions of patients for the care of chronic conditions such
as heart failure or diabetes, are strong factors fostering the
potential for an increase in the incidence of DVT and PE in future years.
Almost all hospitalized patients have at least one risk factor for VTE,
and approximately 40% have three or more risk factors. Without
thromboprophylaxis, the incidence of objectively confirmed,
hospital-acquired DVT is approximately 10% to 40% among medical or
general surgical patients and 40% to 60% following major orthopedic
surgery.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This measure "Compliance with Ventilator
Process Elements during LTCH stay" is a paired quality measure (QM#1
and QM#2); it assesses facility-level compliance with Ventilator
Process Elements for eligible patients in the LTCH setting. Quality
Measure #1: Compliance with Tracheostomy Collar Trial (TCT) or
Spontaneous Breathing Trial (SBT) by the end of the first calendar
day following admission to the LTCH. Quality Measure #2: Compliance
with TCT or SBT during LTCH stay - day 2 through discharge date/ date
when patient is fully weaned. Definitions: i. Invasive mechanical
ventilation: The use of a device to assist or control pulmonary
ventilation, either intermittently or continuously through a
tracheostomy or by endotracheal intubation. ii. Tracheostomy Collar
Trial: Trial of unassisted breathing via a tracheostomy collar (mask)
with aerosol (mist), administered to patients with tracheostomy
tubes. iii. Spontaneous Breathing Trial: Trial of unassisted
breathing for at least X time period and full ventilator support at
night, administered to patients with endotracheal tubes.
- Numerator statement: QM#1: The percentage of patients who
are admitted to a LTCH on invasive mechanical ventilation and for
whom tracheostomy collar trial (TCT) or Spontaneous Breathing Trial
(SBT) was assessed, ordered, and performed by the end of the first
calendar day following admission to the LTCH. (a) Percentage of
patients on invasive mechanical ventilation prior to admission for
whom TCT or SBT was assessed, ordered and performed within 24 hours
of admission. (b) Percentage of patients for whom TCT or SBT was not
assessed, ordered and performed within 24 hours of admission.
(c) Percentage of patients for whom TCT or SBT within 24 hours of
admission was deemed medically inappropriate. QM#2: The total number
of patient ventilator-days for patients discharged (unplanned
discharge, planned discharge, death) during the reporting period who
were admitted to the LTCH requiring invasive mechanical ventilation.
(a) Percentage of ventilator days that TCT or SBT was assessed,
ordered and performed during each day of invasive mechanical
ventilation during the LTCH stay. (b) Percentage of ventilator days
that TCT or SBT was not assessed, ordered and performed during each
day of invasive mechanical ventilation during the LTCH stay.
(c) Percentage of ventilator days that TCT or SBT was deemed
medically inappropriate during each day of invasive mechanical
ventilation LTCH stay.
- Denominator statement: All patients admitted to the LTCH
requiring invasive mechanical ventilation support of any duration at
the time of admission to the LTCH during the reporting period. If a
patient has more than one LTCH stay during the reporting period,
then, each admission will be included in the measure calculation and
reporting for QM#1. For QM#2, the patient population includes all
discharged patients who are admitted to a LTCH on invasive mechanical
ventilation. If a patient has more than one LTCH stay during
the reporting period, then, each discharge will be included in the
measure calculation and reporting for QM#2. Denominator for QM#2 is
the total number of patient ventilator-days for patients discharged
(unplanned discharge, planned discharge, death) during the reporting
period who were admitted to the LTCH requiring invasive mechanical
ventilation support of any duration at the time of admission to the
LTCH.
- Exclusions: Patients identified as unweanable at the time
of admission to an LTCH are excluded. These include (a) patients who
are chronically ventilated (i.e., who have been on invasive
mechanical ventilator support for more than 180 days prior to
admission to the short-stay acute care hospital (if it this stay
preceded the current LTCH stay) or prior to admission to the LTCH,
whichever is earlier) [this would include patients on a ventilator
due to cerebral palsy since childhood); or (b) patients with an acute
or chronic condition (for e.g., irreversible neurological injury or
disease or dysfunction such as ALS, or high (C2) spinal cord injury
that has rendered the patient unweanable. This measure also
excludes patients admitted to LTCH and requiring on non-invasive
mechanical ventilation. LTCHs with denominator counts of less than 20
in the sample during the reporting period will be excluded from
public reporting, owing to small sample size.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: LTCH CARE Data Set
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The measure addresses an important
patient safety priority for LTCHs. It is estimated that 25% of
ventilated patients in LTCHs acquire ventilator-associated pneumonia.
There is evidence for interventions developed to decrease incidence
of ventilator-associated pneumonia and improve ventilator care.
VAP and VAE are associated with substantial morbidity, mortality,
and excess healthcare costs. Further development is
encouraged.
- Public comments received: 3
Rationale for measure provided by HHS
There is evidence for
interventions developed to decrease incidence of ventilator-associated
pneumonia and improve ventilator care 2. VAP and VAE is associated with
substantial morbidity, mortality, and excess healthcare costs. 3.
Patients who develop VAP incur an extra $10K (2005) in hospital costs
(Sadfar 2005). 4. Based on an analysis of CY 2004 MedPAR data for
Medicare beneficiaries, 25% of ventilated patients in LTCHs acquired VAP
(Buczko 2009).
| Patient fall rate
(Program: Long-Term Care Hospitals Quality Reporting
Program; MUC ID: E0141) |
Measure Specifications
- NQF Number (if applicable): 0141
- Description: All documented falls, with or without injury,
experienced by patients on eligible unit types in a calendar quarter.
Reported as Total Falls per 1,000 Patient Days and Unassisted Falls
per 1000 Patient Days. (Total number of falls / Patient days) X 1000
Measure focus is safety. Target population is adult acute care
inpatient and adult rehabilitation patients.
- Numerator statement: Total number of patient falls (with
or without injury to the patient and whether or not assisted by a
staff member) by hospital unit during the calendar month X 1000.
Target population is adult acute care inpatient and adult
rehabilitation patients. Eligible unit types include adult critical
care, adult step-down, adult medical, adult surgical, adult
medical-surgical combined, critical access, adult rehabilitation
in-patient.
- Denominator statement: Patient days by hospital unit
during the calendar month. Included Populations: •Inpatients, short
stay patients, observation patients, and same day surgery patients
who receive care on eligible inpatient units for all or part of a day
on the following unit types: •Adult critical care, step-down,
medical, surgical, medical-surgical combined, critical access, and
adult rehabilitation units. •Patients of any age on an eligible
reporting unit are included in the patient day count
- Exclusions: Other unit types (e.g., pediatric,
psychiatric, obstetrical, etc.)
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Outcome
- Steward: American Nurses Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration by
CMS
- Public comments received: 2
Rationale for measure provided by HHS
The measure focus
addresses several national health goals and priorities, for example: 1.
Recently enacted Centers for Medicare and Medicaid Services regulations
limit hospital reimbursement for care related to fall related injuries.
2. The falls measures fits within the priorities set forth by the
National Priorities Parternship. Specifically, it fits within the
national priority of Making Care Safer (National Priorities Partnership,
2011). 3. As part of their National Patient Safety Goals, The Joint
Commission requires hospitals to reduce the risk of patient harm
resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini,
Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et
al., 2002, 2008). In quarter 3 of 2009, fall rates for nursing units in
participating NDNQI hospitals averaged 3.2 per 1000 patient days
(median = 2.8 per 1000 patient days). About 30% of falls result in injury
disability or death (Shorr, 2008) – particularly in older adults. Injury
falls lead to as much as a 61% increase in patient-care costs and
lengthen a patient’s hospital stay (Fitzpatrick, 2011). Jorgensen (2011)
estimated that by 2020 the direct and indirect costs of injuries related
to falls will reach $54.9 billion. In addition injury falls are a
significant source of liability for hospitals. Agnostini, J.V., Baker,
D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized
and institutionalized older people. In Making health care safer: A
critical analysis of patient safety practices (pp.281-299). Evidence
Report/Technology Assessment Number 43, AHRQ publication No. 01-E058.
Rockville, MD: Agency for Healthcare Research and Quality. Fitzpatrick,
M.A. (2011, March).Meeting the challenge of fall reduction [Supplement].
American Nurse Today, p. 1. Jorgensen, J. (2011, March). Reducing patient
falls: A call to action [Supplement]. American Nurse Today, p.
2-3. National Priorities Partnership. (2011, September). Input to the
Secretary of Health and Human Services on Priorities for the National
Quality Strategy. Retrieved from: http://www.qualityforum.org/Home.aspx
Oliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to
prevent falls and fractures in hospitals and care homes and effect of
cognitive impairment. 384, 82. Shorr, R.I., Guillen, M.k. Rosenblatt,
L.C. (2002). Restraint use, restrain orders, and the risk of falls in
hospitalized patients. Journal of the American Geriatric Society, 50,
526-529. Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving
the capture of fall events in hospitals: Combining a service for
evaluating inpatient falls with an incident report system. Journal of the
American Geriatric Society, 56, 701-704. Unruh, L. (2002). Tends
in adverse events in hospitalized patients. Journal of Healthcare
Quality, 24, 4-10.
Measure Specifications
- NQF Number (if applicable): 0371
- Description: This measure assesses the number of patients
who received venous thromboembolism (VTE) prophylaxis or have
documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start
the day of or the day after hospital admission. This measure is part
of a set of six nationally implemented prevention and treatment
measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE
Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients
Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE
Warfarin Therapy Discharge Instructions and VTE-6: Hospital
Acquired Potentially-Preventable VTE) that are used in The Joint
Commission’s accreditation process.
- Numerator statement: Patients who received VTE prophylaxis
or have documentation why no VTE prophylaxis was given: • the day of
or the day after hospital admission • the day of or the day after
surgery end date for surgeries that start the day of or the day after
hospital admission
- Denominator statement: All discharged hospital
inpatients
- Exclusions: Patients less than 18 years of age • Patients
who have a length of stay (LOS) less than two days and greater than
120 days • Patients with Comfort Measures Only documented on day of
or day after hospital arrival • Patients enrolled in clinical trials
related to VTE • Patients who are direct admits to intensive care
unit (ICU), or transferred to ICU the day of or the day after
hospital admission with ICU LOS greater than or equal to one day •
Patients with ICD-9-CM Principal Diagnosis Code of Mental
Disorders or Stroke as defined in Appendix A, Table 7.01, 8.1 or 8.2
• Patients with ICD-9-CM Principal or Other Diagnosis Codes of
Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03 or 7.04
• Patients with ICD-9-CM Principal Procedure Code of Surgical Care
Improvement Project (SCIP) VTE selected surgeries as defined in
Appendix A, Tables 5.17, 5.19, 5.20, 5.21, 5.22, 5.23,
5.24
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Process
- Steward: The Joint Commission
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending updates
to expand the setting for LTCHs and NQF endorsement of the expanded
measure. MAP members noted concerns about the exclusions for stroke
patients and patients with stays longer than 120 days. Some members
also noted concerns about unintended consequences and that
anticoagulation may not be appropriate for all LTCH patients. MAP
encouraged the relevant NQF Standing Committee to consider this issue
in its review of this measure for endorsement
maintenance.
- Public comments received: 3
Rationale for measure provided by HHS
The estimated annual
incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE),
known collectively as venous thromboembolism (VTE), is approximately
900,000 cases. Of these, approximately one third of the cases (300,000)
are fatal PE, and the remaining two-thirds are non-fatal episodes of DVT
or PE. The majority of fatal events occur as sudden or abrupt death,
underscoring the importance of prevention as the most critical action
step for reducing death from PE. Of the estimated 600,000 cases of
non-fatal venous thromboembolism each year, about 60% are cases of DVT,
and 40% are episodes PE. Among patients who present with symptomatic DVT
as the chief presenting complaint, 50% or more have evidence of pulmonary
embolism (mostly asymptomatic) by diagnostic imaging procedures such as
radionuclide lung scanning or CT imaging .The incidence of venous
thromboembolism increases markedly in patients of age 60 years or more.
Approximately two-thirds of cases of DVT or PE are associated with recent
hospitalization. This is consistent with the 2001 report by The Agency
for Healthcare Research and Quality (AHRQ). AHRQ indicates that “the
appropriate application of effective preventive measures in hospitals has
major potential for improving patient safety by reducing the incidence
of venous thromboembolism.” Although the majority of cases of DVT and
PE are associated with recent hospitalization, many of the patients
present clinically after hospital discharge, because the length of stay
for most surgeries and medical conditions has been markedly reduced in
recent years. The aging of the United States population, the more
extensive use of surgical procedures in older patients, and multiple
hospital admissions of patients for the care of chronic conditions such
as heart failure or diabetes, are strong factors fostering the
potential for an increase in the incidence of DVT and PE in future years.
Almost all hospitalized patients have at least one risk factor for VTE,
and approximately 40% have three or more risk factors. Without
thromboprophylaxis, the incidence of objectively confirmed,
hospital-acquired DVT is approximately 10% to 40% among medical or
general surgical patients and 40% to 60% following major orthopedic
surgery.
Measure Specifications
- NQF Number (if applicable): N/A
- Description: This measure assesses facility-level patient
weaning (liberation) rate for patients in the LTCH setting. This
measure reports the percentage of patients who are discharged from a
Long-Term Care Hospital (LTCH) and reported as successfully (fully)
weaned at discharge. The measure will analyze and report the fully
weaned and not weaned separately for patients discharged alive. The
measure will also analyze and report on weaning status of patients
who die. Definitions: i. Invasive mechanical ventilation: The use
of a device to assist or control pulmonary ventilation, either
intermittently or continuously through a tracheostomy or by
endotracheal intubation. ii. Weaning covers the entire process of
liberating the patient from invasive mechanical ventilation support.
iii. Fully weaned: Patients who are discharged alive from a LTCH and
require no invasive mechanical ventilation support for 72 consecutive
hours or more during 3 consecutive days immediately prior to
discharge. iv. Not weaned (invasive mechanical ventilation
dependent): Patients who require continuous invasive mechanical
ventilation support for more than 12 consecutive hours per day during
each of the 3 consecutive calendar days immediately prior to
discharge.
- Numerator statement: The ventilator weaning rate will be
calculated and reported for the following four numerator components
separately. Each of the numerator components will be calculated and
reported as a percentage of all patients requiring invasive
mechanical ventilation immediately prior to admission to an LTCH: (a)
Fully weaned: Patients who are discharged alive and fully weaned
prior to discharge from an LTCH. (b) Not weaned (invasive mechanical
ventilation dependent): Patients who are discharged alive and require
invasive mechanical ventilation support for more than 12
consecutive hours per day during each of the three consecutive
calendar days immediately prior to discharge. (c) Patients who
died.
- Denominator statement: All patients requiring continuous
invasive mechanical ventilation support of any duration immediately
prior to admission to an LTCH. Patients discharged (unplanned
discharge, planned discharge, death) from the LTCH during the
reporting period. If patient has had more than one LTCH stay during
the reporting period, then, each LTCH stay will be included in the
measure calculation and reporting. If patient is admitted to LTCH,
weaned, has to return to the short-stay acute care hospital for a
procedure, surgery, or some other reason, returns to the LTCH within
3 calendar days, and then, is the discharged from the LTCH, this
is considered one “patient stay”. However, if patient returns to
the LTCH after 3 calendar days, a new admission assessment is
conducted and this will be the start of a “second patient stay” for
this same patient. Each of these two stays will be included in the
measure calculation and reporting.
- Exclusions: Patients identified as unweanable at the time
of admission to an LTCH are excluded. These include (a) patients who
are chronically ventilated (i.e., who have been on invasive
mechanical ventilator support for more than 180 days prior to
admission to the short-stay acute care hospital (if it this stay
preceded the current LTCH stay) or prior to admission to the LTCH,
whichever is earlier) [this would include patients on a ventilator
due to cerebral palsy since childhood); or (b) patients with an acute
or chronic condition (for e.g., irreversible neurological injury or
disease or dysfunction such as ALS, or high (C2) spinal cord injury
that has rendered the patient unweanable. This measure also
excludes patients admitted to LTCH and requiring on non-invasive
mechanical ventilation. LTCHs with denominator counts of less than 20
in the sample during the reporting period will be excluded from
public reporting, owing to small sample size.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: LTCH CARE Data Set
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This measure addresses an important
safety priority for LTCHs. MedPAC estimates that 16% of LTCH patients
use ventilator services. Weaning is the process of decreasing the
amount of support a patient receives from the ventilator. Successful
weaning is associated with decreased morbidity, mortality, and
resource use. Further development is encouraged.
- Public comments received: 5
Rationale for measure provided by HHS
MedPAC analysis of
the Medicare Provider Analysis and Review data found that 16 percent of
LTCH patients used at least one ventilator-related service in 2012. 2. In
2012, Respiratory diagnosis with ventilator support for 96 or more hours
(MS-LTC-DRG-207) represented the most frequently occurring
diagnosis among LTCH patients (11.3% of all discharges). 3. Tracheostomy
with ventilator support for 96 or more hours or primary diagnosis except
face, mouth, and neck without major OR procedure (MS-LTC-DRG-4)
represented an additional 1.3% of all LTCH discharges. 4. These two
diagnosis-related groups account for a total of nearly 18,000 LTCH
discharges. http://www.medpac.gov/chapters/Mar14_Ch11.pdf 5. Weaning
comprises 40 percent of the duration of mechanical ventilation. (Cite)
6. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary
sedation, and even higher mortality. (McIntyre 2012) 7. Complications of
mechanical ventilation include respiratory muscle weakness,
ventilator-associated pneumonia, upper airway pathology (Burns 2014) 8.
Prolonged mechanical ventilation is associated with even higher rates of
mortality and LOS (Zilberberg 2009).
Measure Specifications
- NQF Number (if applicable): 0171
- Description: Percentage of home health stays in which
patients were admitted to an acute care hospital during the 60 days
following the start of the home health stay.
- Numerator statement: Number of home health stays for
patients who have a Medicare claim for an admission to an acute care
hospital in the 60 days following the start of the home health
stay.[For reference, numerator for endorsed measure from QPS: Number
of home health stays for patients who have a Medicare claim for an
unplanned admission to an acute care hospital in the 60 days
following the start of the home health stay.]
- Denominator statement: Number of home health stays that
begin during the 12-month observation period. A home health stay is a
sequence of home health payment episodes separated from other home
health payment episodes by at least 60 days.
- Exclusions: Home health stays that begin with a Low
Utilization Payment Adjustment (LUPA) claim. Home health stays in
which the patient receives service from multiple agencies during the
first 60 days. Home health stays for patients who are not
continuously enrolled in fee-for-service Medicare for the 6 months
prior to and the 60 days following the start of the home health stay
or until death.[For reference, exclusions for endorsed measure from
QPS: The following are excluded: home health stays for patients who
are not continuously enrolled in fee-for-service Medicare during the
numerator window (60 days following the start of the home health
stay) or until death; home health stays that begin with a Low
Utilization Payment Adjustment (LUPA) claim; home health stays in
which the patient receives service from multiple agencies during the
first 60 days; and home health stays for patients who are not
continuously enrolled in fee-for-service Medicare for the 6 months
prior to the start of the home health stay.]
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP noted that this measure meets a
critical program objective by encouraging coordination and shared
accountability and promoting alignment across quality measurement
reporting programs. This measure addresses a gap of post-acute
outcome measures and supports alignment with Home Health Quality
Reporting program. It also addresses a PAC/LTC core concept of
avoidable admissions and included in the MAP families of
affordability, care coordination, and hospice. MAP members noted that
integrating this measure into the MSSP could help to lower
readmissions.
- Public comments received: 3
Rationale for measure provided by HHS
Addresses a gap of
post-acute outcome measures and supports alignment with Home Health
quality reporting.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration per
CMS.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Intermediate Outcome
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 1
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.
Measure Specifications
- NQF Number (if applicable): 2111
- Description: The percentage of individuals 65 years of age
and older with dementia who are receiving an antipsychotic medication
without evidence of a psychotic disorder or related
condition.
- Numerator statement: The number of patients in the
denominator who had at least one prescription and > 30 days supply
for any antipsychotic medication during the measurement period and do
not have a diagnosis of schizophrenia, bipolar disorder, Huntington’s
disease or Tourette’s Syndrome.
- Denominator statement: All patients 65 years of age and
older continuously enrolled during the measurement period with a
diagnosis of dementia and/or two or more prescription claims and
>60 days supply for a cholinesterase inhibitor or an NMDA receptor
antagonist.
- Exclusions: None
- HHS NQS Priority: Making Care Safer
- HHS Data Source: Administrative Claims
- Measure type: Process
- Steward: Pharmacy Quality Alliance
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP noted that this measure addresses
a critical program objective of including high-value measures in the
set such as appropriate use measures. It also addresses a PAC/LTC
core concept of inappropriate medication use. The measure promotes
alignment as it is included in the MAP duals eligible beneficiary
Family of Measures. MAP members reiterated that this measure
addresses a large problem for persons with dementia.
- Public comments received: 2
Rationale for measure provided by HHS
Recommended by MAP
for dual eligible beneficiaries.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this measure harmonized with MUC X3769 to a single set of
specifications
- Public comments received: 3
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for
imaging.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for
imaging.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for
imaging.
- Public comments received: 0
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for
imaging.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supports this NQF-endorsed
measure that is consistent with most recent guidelines. MAP
acknowledges concerns about patients who decline screening and the
quality of mammography services.
- Public comments received: 1
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).
Measure Specifications
- 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: Best Practice of Healthy Living
- HHS Data Source: Claims, Paper Medical Record
- Measure type: Process
- Steward: National Committee for Quality Assurance
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: The measure does not apply to the
Medicare population.
- Public comments received: 0
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure for chronic opioid
use.
- Public comments received: 2
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for stroke
care.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of these care coordination measures (X3283, X3302,X3466, X3465) for
MSSP.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of these care coordination measures (X3283, X3302,X3466, X3465) for
MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for emergency
care.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: As noted in the discussion for PQRS,
MAP has significant concerns about the measure including lack of
evidence fore general screening. MAP acknowledges this is a very
important condition for the Medicare population but would revisit the
measure when development is complete.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for cancer
care.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for diabetes
care.
- Public comments received: 3
Rationale for measure provided by HHS
Clinically important
area for at risk population and aligns with PQRS and MU
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP did not reach consensus on this
measure for the PQRS-based programs.
- Public comments received: 4
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supports this
measure for MSSP acknowledging the ongoing controversy and changing
guidelines around BP target values. MAP members are concerned about
over treatment of high blood pressure in older patients that is
addressed in this measure. MAP support is conditional for MSSP on
review by NQF pending final hypertension guidelines from AHA/ACC due
in 2015.
- Public comments received: 0
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of these care coordination measures (X3283, X3302,X3466, X3465) for
MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of these care coordination measures (X3283, X3302,X3466, X3465) for
MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: Optimal Vascular Care measure (E0076)
contains this measure as a component of the composite. Both measures
would be redundant.
- Public comments received: 0
Rationale for measure provided by HHS
Clinically important
area and aligns with PQRS
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 2
Rationale for measure provided by HHS
Clinically important
area for at risk populations.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for coronary heart
disease.
- Public comments received: 0
Rationale for measure provided by HHS
Clinically important
topic and aligns with PQRS
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this NQF-endorsed
outcome measure for depression. The measure should align with other
federal programs - the PQRS measure is focused on 12 month remission.
This measure should be paired with measure 0712 Use of
PHQ9.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this NQF-endorsed
measure only if paired with the depression outcome measure
E0711.
- Public comments received: 0
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 1
Rationale for measure provided by HHS
Clinically important
area for at risk population and aligns with PQRS and MU
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for diabetes
care.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for dementia
care.
- Public comments received: 0
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.
Measure Specifications
- NQF Number (if applicable): 0419
- Description: Percentage of specified visits for patients
aged 18 years and older for which the eligible professional attests
to documenting a list of current medications to the best of his/her
knowledge and ability. This list must include ALL prescriptions,
over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)
supplements AND must contain the medications’ name, dosage, frequency
and route of administration
- Numerator statement: Percentage of specified visits for
patients aged 18 years and older for which the eligible professional
attests to documenting a list of current medications to the best of
his/her knowledge and ability. This list must include ALL
prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain
the medications’ name, dosage, frequency and route of
administration[For reference, the numerator for endorsed measure on
QPS: Eligible professional attests to documenting, updating or
reviewing a patient´s current medications using all immediate
resources available on the date of the encounter. This list must
include ALL prescriptions, over-the counters, herbals,
vitamin/mineral/dietary (nutritional) supplements AND must contain
the medications’ name, dosages, frequency and routeNUMERATOR NOTE:
The eligible professional must document in the medical record they
obtained, updated, or reviewed a medication list on the date of the
encounter. Eligible professionals reporting this measure may document
medication information received from the patient, authorized
representative(s), caregiver(s) or other available healthcare
resources. G8427 should be reported if the eligible professional
documented that the patient is not currently taking any
medications.]
- Denominator statement: All visits occurring during the 12
month reporting period for patients aged 18 years and older on the
date of the encounter where one or more CPT or HCPCS codes are
reported on the claims submission for that encounter. All discussed
coding is listed in "2a1.7. Denominator Details" section below.[For
reference, denominator for endorsed measure from QPS: All visits for
patients aged 18 years and older]
- Exclusions: A patient is not eligible or excluded (B) from
the performance denominator (PD) if one or more of the following
reason exists: • Patient is in an urgent or emergent medical
situation where time is of the essence and to delay treatment would
jeopardize the patient’s health status.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP noted that this measure addresses
a critical program objective to encourage coordination and shared
accountability across settings. It addresses the NQS priority of
safety and included in the MAP duals family. It promotes alignment
across federal programs, and recently finalized for use in
MSSP.
- Public comments received: 2
Rationale for measure provided by HHS
Meets gap in
medication reconciliation measures and aligns with PQRS and MU. In 2005,
the rate of medication errors during hospitalization was estimated to be
52 per 100 admissions, or 70 per 1,000 patient days. Emerging research
suggests the scope of medication-related errors in ambulatory settings is
as or more extensive than during hospitalization. Ambulatory visits
result in a prescription for medication 50 to 70% of the time. One
study estimated the rate of adverse drug events (ADE) in the ambulatory
setting to be 27 per 100 patients. It is estimated that between 2004 and
2005, in the United States 701,547 patients were treated for ADEs in
emergency departments and 117,318 patients were hospitalized for injuries
caused by an ADE. Individuals aged 65 years and older are more likely
than any other population group to require treatment in the emergency
department for ADEs (American Medical Association (AMA), 2010). In the
United States, it is estimated that in any given week, most adults aged
18 years and older take at least one prescription medication, OTC drug,
vitamin, mineral, herbal product or supplement, while 10 percent take
five or more. Overall, 26 percent of the population takes herbal products
and supplements, and 30 percent of prescription drug users take an
herbal product or supplement. In all settings of care, drug-drug
interactions are significant, but undetected causes of ADEs. Drug-drug
interactions—including interactions between drugs a patient is known to
be taking—are frequently not recognized. Controversy, confusion and
uncertainty about the significance of many drug-drug interactions further
increase risk and opportunity for ADEs (AMA, 2010).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure for chronic opioid
use.
- Public comments received: 4
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure for chronic opioid
use.
- Public comments received: 3
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)
Measure Specifications
- 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 (please list in
GTL comment field)
- Measure type: Outcome
- Steward: American College of Radiology
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for
imaging.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for colonoscopy
performance.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this high-value outcome measure for a condition prevalent in the
Medicare population. MAP hopes this measure will be available for use
very soon.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this measure for patients with osteoarthritis-a prevalent
condition in the Medicare population.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this high-value outcome measure for a procedure frequently
performed in the Medicare population. MAP hopes this measure will be
available for use very soon.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this high-value outcome measure for a procedure frequently
performed in the Medicare population. MAP hopes this measure will be
available for use very soon.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP supports continued development of
this follow-up measure for population screening for Hepatitis C
consistent with CDC guidelines. This measure should be combined with
the screening measure X3512 Hepatitis C: One-Time Screening for
Hepatitis C Virus (HCV) for Patients at Risk.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP supports continued development of
this population screening measure for Hepatitis C consistent with CDC
guidelines. This measure should be combined with the screening
measure X3816 Hepatitis C: Appropriate Screening Follow-Up for
Patients Identified with Hepatitis C Virus (HCV)
Infection.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 3
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
vir
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP because it does not
apply to the Medicare population.
- Public comments received: 0
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for imaging or
emergency care.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: For a smaller, focused group of
measure for MSSP this outcome measure would be most useful as part of
a composite. If the MSSP measure group were larger, perhaps this
outcome measures would be useful alone.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 1
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- NQF Number (if applicable): 0514
- Description: This measure calculates the percentage of MRI
of the Lumbar Spine studies with a diagnosis of low back pain on the
imaging claim and for which the patient did not have prior
claims-based evidence of antecedent conservative therapy. Antecedent
conservative therapy may include (see subsequent details for codes):
1. Claim(s) for physical therapy in the 60 days preceding the Lumbar
Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative
treatment in the 60 days preceding the Lumbar Spine MRI. 3.
Claim(s) for evaluation and management in the period >28 days and
<60 days preceding the Lumbar Spine MRI.
- Numerator statement: MRI of the lumbar spine studies with
a diagnosis of low back pain (from the denominator) without the
patient having claims-based evidence of prior antecedent conservative
therapy.[For reference, additional numerator text for endorsed
measure from QPS: The numerator measurement of prior conservative
therapy is based on the claim date of the MRI of the lumbar spine
from the denominator, with the prior conservative therapy within the
defined time periods relative to each MRI lumbar spine claim
(i.e., a patient can be included in the numerator count more than
once, if the patient had more than one MRI lumbar spine procedure in
the measurement period and the MRI lumbar spine procedure occurred on
different days).]
- Denominator statement: MRI of the lumbar spine studies
with a diagnosis of low back pain on the imaging claim.[For
reference, additional denominator text for endorsed measure from QPS:
The diagnosis of low back pain must be on the MRI lumbar spine claim
(i.e., the lumbar spine MRI must be billed with a low back pain
diagnosis in one of the diagnoses fields on the claim). MRI lumbar
spine studies without a diagnosis of low back pain on the claim are
not included in the denominator count. If a patient had more than one
MRI lumbar spine study for a diagnosis of low back pain on the
same day only one study would be counted, but if a patient had
multiple MRI lumbar spine studies with a diagnosis of low back pain
on the claim during the measurement period each study would be
counted (i.e., a patient can be included in the denominator count
more than once).]
- Exclusions: Indications for measure exclusion include any
patients with the following procedures or diagnosis codes: •
Patients with lumbar spine surgery in the 90 days prior to MRI: •
Cancer (Within 12 months prior to MRI procedure. A cancer exclusion
diagnosis must be in one of the diagnoses fields of any inpatient,
outpatient or Carrier claims) • Trauma: (Within 45 days prior to MRI
procedure. An exclusion diagnosis must be in one of the diagnoses
fields of any inpatient, outpatient or Carrier claims) • IV Drug
Abuse: (Within 12 months prior to MRI procedure. An exclusion
diagnosis must be in one of the diagnoses fields of any inpatient,
outpatient or Carrier claims.) • Neurologic Impairment: (Within 12
months prior to MRI procedure. An exclusion diagnosis must be in one
of the diagnoses fields of any inpatient, outpatient or Carrier
claims.) • Human Immunodeficiency Virus (HIV): (Within 12 months
prior to MRI procedure An exclusion diagnosis must be in one of the
diagnoses fields of any inpatient, outpatient or Carrier
claims.) • Unspecified Immune Deficiencies: (Within 12 months prior
to MRI procedure. An exclusion diagnosis must be in one of the
diagnoses fields of any inpatient, outpatient or Carrier claims.) •
Intraspinal abscess: (An exclusion diagnosis must be in one of the
diagnoses fields on the MRI lumbar spine claim.)
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims
- Measure type: Efficiency
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending
resolution of data concerns. MAP conditionally supported this measure
pending resolution of data concerns. Specifically, MSSP may have
difficulty accessing NHSN data and would need to coordinate with the
CDC to obtain the information. MAP did acknowledge concerns raised by
providers specializing in the treatment of spinal cord injuries and
encouraged further consideration on the trade-offs of including these
patients in this measure population.
- Public comments received: 4
Rationale for measure provided by HHS
Addresses imaging
efficiency/utilization gap and supports program alignment.
Measure Specifications
- NQF Number (if applicable):
- Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to
avoid bladder and urethral trauma, keeping the urine collection bag
below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI
monitoring, leads to improved patient outcomes and provides a
mechanism for identifying improvements and quality efforts.
- Numerator statement: Total number of observed
healthcare-associated CAUTI among patients in bedded inpatient care
locations (excluding patients in Level II or III neonatal
ICUs).
- Denominator statement: S.7. Denominator Statement: Total
number of indwelling urinary catheter days for each location under
surveillance for CAUTI during the data period. S.10. Denominator
Exclusions: The following are not considered indwelling catheters by
NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In
and out” catheterizations 4. Nephrostomy tubes Note, that if a
patient has either a nephrostomy tube or a suprapubic catheter and
also has an indwelling urinary catheter, the indwelling urinary
catheter will be included in the CAUTI surveillance.
- Exclusions: The following are not considered indwelling
catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom
catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note,
that if a patient has either a nephrostomy tube or a suprapubic
catheter and also has an indwelling urinary catheter, the indwelling
urinary catheter will be included in the CAUTI
surveillance.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supported this
measure pending resolution of data concerns. Specifically, MSSP may
have difficulty accessing NHSN data and would need to coordinate with
the CDC to obtain the information. MAP did acknowledge concerns
raised by providers specializing in the treatment of spinal cord
injuries and encouraged further consideration on the trade-offs of
including these patients in this measure population.
- Public comments received: 6
Rationale for measure provided by HHS
Measure has been
revised and now in NQF re-endorsement process. CAUTI can be minimized by
a collection of prevention efforts. These include reducing the number of
unnecessary indwelling catheters inserted, removing indwelling catheters
at the earliest possible time, securing catheters to the patient´s leg
to avoid bladder and urethral trauma, keeping the urine collection
bag below the level of the bladder, and utilizing aseptic technique for
urinary catheter insertion. These efforts will result in decreased
morbidity and mortality and reduce healthcare costs. Use of this measure
to track CAUTIs through a nationalized standard for HAI monitoring, leads
to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another
risk adjustment methodology besides the Standardized Infection Ratio. The
two risk adjustment methodologies are: 1. Standardized Infection Ratio
(annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any
number of stratified groups of data. CAUTI incidence rates stratified by
patient care location type and in some instances, location bed size
and type of medical school affiliation which form the basis of the
population standardization. Example: predicted numbers of CAUTI (and
CAUTI rates) in a medical ICU are not the same as in an SICU. See also
Scientific Validity section for further information on risk adjustment
and variables. 2. Adjusted Ranking Metric (annual aggregation) The
adjusted ranking metric (ARM) combines the method of indirect
standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in
the unadjusted SIR mentioned above. A Bayesian posterior
distribution constructed through Monte Carlo Markov Chain sampling is
used to produce the adjusted numerator.
Measure Specifications
- NQF Number (if applicable):
- Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of
lines are recommended. These efforts result in decreased morbidity
and mortality and reduced healthcare costs.
- Numerator statement: Total number of observed
healthcare-associated CLABSI among patients in bedded inpatient care
locations.
- Denominator statement: S.7. Denominator Statement: Total
number of central line days for each location under surveillance for
CLABSI during the data period. S.10. Denominator Exclusions: 1.
Pacemaker wires and other non-lumened devices inserted into central
blood vessels or the heart are excluded as CLs. 2. Extracorporeal
membrane oxygenation lines, femoral arterial catheters, intraaortic
balloon pump devices, and hemodialysis reliable outflow
catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines
are excluded as CLs.
- Exclusions: Pacemaker wires and other non-lumened devices
inserted into central blood vessels or the heart are excluded as CLs.
2. Extracorporeal membrane oxygenation lines, femoral arterial
catheters, intraaortic balloon pump devices, and hemodialysis
reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral
intravenous lines are excluded as CLs.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status:
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP was conditionally supportive of
the implementation of an updated version of a measure currently in
the MSSP Program pending resolution of data concerns. Specifically,
MSSP may have difficulty accessing NHSN data and would need to
coordinate with the CDC to obtain the information. The updated
measure was recently reviewed and recommended by the NQF Safety
Standing Committee. Implementing this updated measure would extend
the measure to hospital settings outside the ICU and add another risk
adjustment methodology. The two risk adjustment methodologies are:
Standardized Infection Ratio (SIR) uses a stratification
approach to compare CLABSI incidence rates. For example, the
stratification can be by the hospital’s patient care location as the
predicted number of CLABSIs in a medical ICU may be different then a
NICU. Adjusted Ranking Metric (ARM) uses a more complex Bayesian
estimation technique to account for the small sample sizes that may
be present in the strata described in the SIR above. To adjust for
this potentially low precision and/or reliability due to sample size,
a statistical adjustment is made to the numerator. The MAP noted that
expanding the measure from the ICU to other locations in the
hospital significantly adjusts the measure and measure use experience
is needed.
- Public comments received: 0
Rationale for measure provided by HHS
Updated version of a
current measure in IQR, HVBP, and HACRP CLABSI can be minimized through
proper management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs. Use of this measure to track
CLABSIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and evaluating prevention efforts. Additionally, CDC has
added another risk adjustment methodology besides the Standardized
Infection Ratio. The two risk adjustment methodologies are: 1.
Standardized Infection Ratio (annual and quarter aggregation) The SIR is
constructed by using an indirect standardization method for summarizing
HAI experience across any number of stratified groups of data.
CLABSI incidence rates stratified by patient care location type and in
some instances, location bed size and type of medical school affiliation
which form the basis of the population standardization. Example:
predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the
method of indirect standardization with a Bayesian random effects
hierarchical model to account for the potentially low precision and/or
reliability inherent in the unadjusted SIR mentioned above. A Bayesian
posterior distribution constructed through Monte Carlo Markov Chain
sampling is used to produce the adjusted numerator.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supports this
composite measure with a patient-reported outcome component for
asthma after strong consideration of raising the age range as noted
in the public comment from American Association of Allergy and
Immunology. Asthma is becoming more prevalent in the older
population.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supports this
revised composite measures for vascular care that has removed the
lipid component due to recent changes in the guidelines. Conditional
on successful maintenance review of revised measure by
NQF.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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%).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure for headaches.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- NQF Number (if applicable): 2158
- Description: The MSPB Measure assesses the cost of
services performed by hospitals and other healthcare providers during
an MSPB hospitalization episode, which comprises the period
immediately prior to, during, and following a patient’s hospital
stay. Beneficiary populations eligible for the MSPB calculation
include Medicare beneficiaries enrolled in Medicare Parts A and B who
were discharged from short-term acute hospitals during the period of
performance.[Note: Description differs from older version of measure
listed on QPS.]
- Numerator statement: The numerator for a hospital’s MSPB
Measure is the hospital’s average MSPB Amount, which is defined as
the sum of standardized, risk-adjusted spending across all of a
hospital’s eligible episodes divided by the number of episodes for
that hospital.
- Denominator statement: The denominator for a hospital’s
MSPB Measure is the median MSPB Amount across all episodes
nationally.
- Exclusions: None
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims
- Measure type: Cost/ Resource Use
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP was supportive of this
cost/resource measure that captures services delivered between 3 days
prior to an acute inpatient hospital admission through the period 30
days after discharge. As a MAP identified high-value measurement
area, this measure seeks incentive hospitals to improve care
coordination and reduce fragmentation across the health care delivery
system. MAP noted that this measure also promotes alignment across
quality measurement reporting programs since it is used in the
Hospital Inpatient Quality Reporting program, and the Hospital
Value-Based Purchasing program. This measure is included in the MAP
Affordability Family of Measures along with MAP Duals Family of
Measures.
- Public comments received: 3
Rationale for measure provided by HHS
Addresses gap of
cost/resource use and aligns with other quality reporting programs.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: The measure does not apply to the
Medicare population.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 0
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 0
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure for
MSSP only if rolled up into a composite measure for pelvic
surgery.
- Public comments received: 2
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure.
- Public comments received: 1
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).
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process [Change made from publically posted
MUC list after discussion with CMS]
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure for colonoscopy
performance.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if rolled up into a composite measure.
- Public comments received: 3
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 1
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual eMeasure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supports this
measure that is specified at the community level after testing at the
ACO level of analysis.
- Public comments received: 0
Rationale for measure provided by HHS
Addresses prevention
and is a composite with PQIs already in program.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP would support this measure for
MSSP only if it rolled up into a composite measure.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: The measure does not apply to the
Medicare population.
- Public comments received: 1
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).
Measure Specifications
- 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 (please list in GTL comment field)
- Measure type: Outcome
- Steward: American Urogynecologic Society
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure for
MSSP only if rolled up into a composite measure for pelvic
surgery.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure for
MSSP only if rolled up into a composite measure for pelvic
surgery.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure for
MSSP only if rolled up into a composite measure for pelvic
surgery.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP would support this measure only
if rolled up into a composite measure for headaches.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 0
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support narrow-focused,
process measures for MSSP.
- Public comments received: 0
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.
Measure Specifications
- NQF Number (if applicable): 2510
- Description: This measure estimates the risk-standardized
rate of all-cause, unplanned, hospital readmissions for patients who
have been admitted to a Skilled Nursing Facility (SNF) (Medicare
fee-for-service [FFS] beneficiaries) within 30 days of discharge from
their prior proximal hospitalization. The prior proximal
hospitalization is defined as an admission to an IPPS, CAH, or a
psychiatric hospital. The measure is based on data for 12 months of
SNF admissions. A risk-adjusted readmission rate for each facility
is calculated as follows: Step 1: Calculate the standardized
risk ratio of the predicted number of readmissions at the facility
divided by the expected number of readmissions for the same patients
if treated at the average facility. The magnitude of the
risk-standardized ratio is the indicator of a facility’s effects on
readmission rates. Step 2: The standardized risk ratio is then
multiplied by the mean rate of readmission in the population (i.e.,
all Medicare FFS patients included in the measure) to generate the
facility-level standardized readmission rate. For this measure,
readmissions that are usually for planned procedures are excluded.
Please refer to the Appendix, Tables 1 - 5 for a list of planned
procedures. The measure specifications are designed to harmonize
with CMS’s hospital-wide readmission (HWR) measure to the greatest
extent possible. The HWR (NQF #1789) estimates the hospital-level,
risk-standardize rate of unplanned, all-cause readmissions within 30
days of a hospital discharge and uses the same 30-day risk window as
the SNFRM.
- Numerator statement: The numerator is defined as the
risk-adjusted estimate of the number of unplanned readmissions that
occurred within 30 days from discharge from the prior proximal acute
hospitalization.
- Denominator statement: The denominator includes all
patients who have been admitted to a SNF within one day of discharge
from a prior proximal hospitalization, taking denominator exclusions
into account.
- Exclusions: Numerator exclusions: We exclude for planned
readmissions as per the HWR measure. Denominator exclusions: The
following are excluded from the denominator: 1. SNF stays where the
patient had one or more intervening post-acute care (PAC) admissions
(inpatient rehabilitation facility [IRF] or long-term care hospital
[LTCH]) which occurred either between the prior proximal hospital
discharge and SNF admission or after the SNF discharge, within the
30-day risk window. Also excluded are SNF admissions where the
patient had multiple SNF admissions after the prior proximal
hospitalization, within the 30-day risk window. 2. SNF stays with a
gap of greater than 1 day between discharge from the prior proximal
hospitalization and the SNF admission. 3. SNF stays where the patient
did not have at least 12 months of FFS Medicare enrollment prior to
the proximal hospital discharge (measured as enrollment during the
month of proximal hospital discharge and for the 11 months prior to
that discharge). 4. SNF stays in which the patient did not have FFS
Medicare enrollment for the entire risk period (measured as
enrollment during the month of proximal hospital discharge and the
month following the month of discharge). 5. SNF stays in which the
principal diagnosis for the prior proximal hospitalization was
for the medical treatment of cancer. Patients with cancer whose
principal diagnosis from the prior proximal hospitalization was for
other diagnoses or for surgical treatment of their cancer remain in
the measure. 6. SNF stays where the patient was discharged from the
SNF against medical advice. 7. SNF stays in which the principal
primary diagnosis for the prior proximal hospitalization was for
“rehabilitation care; fitting of prostheses and for the adjustment of
devices”.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP agreed that integrating this
measure into the MSSP could help to lower readmissions. Some members
did raise concerns that this measure could discourage necessary
hospitalizations.
- Public comments received: 4
Rationale for measure provided by HHS
The Skilled Nursing
Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP
measure.
Measure Specifications
- 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: EHR, Paper Medical Record, Registry
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development of
this measures for a prevalent condition in the Medicare
population.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Several Workgroup members had
significant concerns that the two components relating to drug use are
not evidence based. A majority of the Workgroup, however, encouraged
further development of the measure noting that prescription and
illicit drug abuse is a large and growing problem.Some workgroup
members suggested that screening very old patients may not be
worthwhile. Public comments also indicated concerns that complying
with non-evidence-based processes will take resources away from
alcohol screening.
- Public comments received: 7
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.
Measure Specifications
- NQF Number (if applicable): 0513
- Description: This measure calculates the ratio of thorax
studies that are performed with and without contrast out of all
thorax studies performed (those with contrast, those without
contrast, and those with both). The measure is calculated based on a
one year window of claims data.
- Numerator statement: The number of thorax CT studies with
and without contrast (combined studies).[For reference, numerator for
NQF endorsed measure in QPS: The number of thorax CT studies with and
without contrast (herein, ´combined studies´).Sum of global and
technical units associated with the following CPT code:71270 – CT
Thorax with and without ContrastA technical unit can be identified by
a modifier code of TC. A global unit can be identified by the absence
of a TC or 26 modifier code.Thorax CT studies can be billed
separately for the technical and professional components, or billed
globally, which includes both the professional and technical
components.Professional component claims will outnumber technical
component claims due to over-reads.To capture all outpatient volume
facility claims, typically paid under the OPPS/APC methodology,
global and TC claims should be considered, and to avoid double
counting of professional component claims (i.e., 26
modifier).]
- Denominator statement: The number of thorax CT studies
performed (with contrast, without contrast or both with and without
contrast).[For reference, denominator for NQF endorsed measure in
QPS: The number of thorax CT studies performed (with contrast,
without contrast, or both with and without contrast) on Medicare
beneficiaries within a 12-month time window.Sum of global and
technical units for the following CPT codes:71250 - CT thorax without
contrast71260 – CT thorax with contrast71270 – CT thorax with and
without contrast]
- Exclusions: None
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims
- Measure type: Efficiency
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP did not support the use of this
measure in this program noting that the measures that are used for
the Medicare Shared Savings program should focus on measures of
underuse since the program is designed to hold providers accountable
for utilization. It is important that measures ensure that providers
are not underutilizing appropriate care. MAP noted that this is an
important measure, but not for this program or for providers managing
a more comprehensive payment.
- Public comments received: 0
Rationale for measure provided by HHS
Addresses gaps in
imaging efficiency, utilization, and patient safety while supporting
alignment with other quality reporting programs.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP does not support this measure
because the MSSP already includes a cost component. The program does
not need two cost measures calculated via different
methods.
- Public comments received: 1
Rationale for measure provided by HHS
Addresses gap in
cost/resource use and aligns with VM
Measure Specifications
- 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 (please list in GTL
comment field)
- Measure type: Efficiency
- Steward: American Gastroenterological Association
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this measure harmonized with MUC X3758 to a single set of
specifications
- Public comments received: 2
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;
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not support this measure for
MSSP because it only applies to ages 18-50 years. A gap is noted in
measures for overuse of imaging for low back pain in the older
population.
- Public comments received: 1
Rationale for measure provided by HHS
Aligns with PQRS
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP does not encourage further
development of this individual measure for MSSP. MAP recommends
rolled-up or composite measures for specific conditions for
MSSP.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This eMeasure aligns with PQRS and
will be useful in the Medicaid EHR Incentive program.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration per
CMS.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that the literature
supports the role of alcohol in trauma - this measure will stimulate
a practice change. This is a screening measure with follow-up. ?This
measure is also supported for PQRS and is important for the Medicaid
EHR Incentive program.
- Public comments received: 5
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This eMeasure is also supported for
PQRS and will be useful for the Medicaid EHR Incentive
program.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP supports development of this
eMeasure. The non-eMeasure version is already in PQRS and is a high
priority quality issue for dual eligibles.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP concludes that 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".
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this suite of related measures related to care coordination
including X3283, X3465, X3466. MAP believes these measures are
necessary but not sufficient to measure quality for care
coordination. The developers indicate that these are "building block"
measures. MAP notes that measure’s title should be revised to
reflected that a referral was initiated and not closed. Good EHR
systems are needed and measures should assess whether systems are
being used effectively. Streamlining the transmission of notes that
PCP’s receive through EHR’s is necessary -- there are multiple
pathways within an EHR to get a response from a specialist. The
measure applies to all EPs.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The Medicare Annual Wellness Visit
specifies "detection of any cognitive impairment". No evidence for
general screening for cognitive impairment. Providers should have
heightened awareness and finely tuned antennae for case finding for
dementia. Important for dual eligibles. Important topic but
significant concerns with the measure. MAP would like to revisit when
measure is more fully developed.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This measure with MUC # X3283 and
X3465 are building blocks toward a more effective system. MAP
suggests it would be better to separate asthma from chest pain - the
measure is more appropriate for asthma and 7 day follow-up is more
appropriate than 3 days for the clinical course. Chest pain should
specify "atraumatic chest pain". MAP suggests this measure should
include "or designee" as in X 3465.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Suite of related measures include
X3283, X3465, X3466. MAP agrees that including "or designee" is
appropriate - similar language should be used in X 3466.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this 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. This
measure is also important for dual eligibles. Conditional on NQF
review and further consideration of evidence for age specifications.
Suggest amending denominator to "on a antihyperglycemic
medication other than metformin…" Metformin does not have
hypoglycemic side effects.
- Public comments received: 5
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
for this care coordination for a condition important in Medicare and
for dual eligibles. The measure should include advanced directives
and patient goals. Proxy must be informed and aware of patient
wishes. Aligns with PQRS.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that this measure has an
overly large denominator and should consider principal diagnosis or
pain/function threshold to be captured in the denominator. MAP
prefers development as a patient-reported functional 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. A true functional status
measure would be related to the functional status measures for hip
and knee replacement (X3482 and X3483).
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP is delighted to see development
of true patient-reported, functional outcome measures like this. MAP
hopes the eMeasure will be ready for use very soon and notes that the
same tool should be used to assess before and after
surgery.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP is delighted to see development
of true patient-reported, functional outcome measures like this. MAP
hopes the eMeasure will be ready for use very soon and notes that the
same tool should be used to assess before and after
surgery.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: NQF did not approve this eMeasure for
Trial Use due to lack of evidence of relationship to patient
outcomes. Monitoring of blood level is not related to response to
therapy.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: NQF approved this eMeasure for Trial
Use in 2014. Aligns with PQRS.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
process eMeasure of appropriate treatment after a positive HCV
screening test. MAP suggests combining or pairing with X3512. This
eMeasure is also supported for PQRS.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this population health screening eMeasure aligned with CDC
recommendations and a?aligns with PQRS.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This eMeasure 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. This eMeasure is also under
consideration for PQRS.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: 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. This measure will be important for the Medicais EHR Incentive
program.
- Public comments received: 2
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
eMeasure version of an NQF-endorsed measure that captures all
patients on warfarin regardless of diagnosis. This is a patient
safety measure.
- Public comments received: 2
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP suggested that it is unclear how
to ascertain that effective screening occurred and the measure should
include follow-up. MAP supports integrating behavioral health into
primary care - teams may have a variety of appropriate
providers.
- Public comments received: 5
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP indicated that alcohol screening
and brief intervention is evidence based and encouraged further
development of this eMeasure.
- Public comments received: 6
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development
and suggests broadening the age range and combing this measure with
E1507 Risky Behavior Assessment or Counseling by age 18
years.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development
and suggests broadening the age range and combining with measure
E1406 for parsimony.
- Public comments received: 1
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
Measure Specifications
- 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: EHR, Paper Medical Record, Registry
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that the measure conforms
to new guidelines for statin use and should replace prior measures
based on old guidelines. The measure does not address intensity of
statins. The specifications for LDL > 190 does not include age
specifications included in the guidelines.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Overlap with PQRS measure #305 (NQF
#0004) Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment (IET). This measure 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.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Overlap with PQRS measure #305 (NQF
#0004) Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment (IET). This measure 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.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Several Workgroup members had
significant concerns that the two components relating to drug use are
not evidence based. A majority of the Workgroup, however, encouraged
further development of the measure noting that prescription and
illicit drug abuse is a large and growing problem. Public comments
also indicated concerns that complying with non-evidence-based
processes will take resources away from alcohol screening. The
Clinician Workgroup votes 67% to encourage further development; 33%
voted against.
- Public comments received: 11
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This eMeasure aligns with PQRS.
- Public comments received: 3
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.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patient-drug days with
administration of anticoagulants requiring renal dosing with at least
one error in renal dosing
- Numerator statement: The total number of patient-drug days
with at least one renal dosing error.
- Denominator statement: The total number of patient-drug
days with administration of anticoagulants requiring renal
dosing.
- Exclusions: Admissions for individuals less than 18 years
old. 2. Admissions that are for observation only. 3. Admissions with
length of stay greater than or equal to 120 days. 4. Admissions with
length of stay less than 24 hours. 5. Drugs administered in the OR.
6. Admissions on dialysis of any kind. 7. Antibiotics given less than
2 hours prior to surgery and up to 24 hours post-surgery are ignored.
Ignore the first dose of antibiotic more than 2 hours before surgery
and the first dose more than 24 hours after surgery. 8. First 96
hours of drugs for patients with labor & delivery
codes.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP members agreed that this measure
addresses a critical gap in adverse drug events. Anticoagulants are a
high risk class of drugs that should be administered carefully to
renal patients, for whom the effects of many drugs differ from
non-renal patients. MAP encouraged further development of this
measure at the facility level, testing, and submission to NQF for
endorsement. MAP encouraged the developers to fully specify this as
an e-Measure, and NQF should review the e-measure for endorsement.
This measure is also under review for the Hospital Inpatient Quality
Reporting program.
- Public comments received: 5
Rationale for measure provided by HHS
Additional process
measure to assess medication adverse drug event associated with widely
used anticoagulants. The anticipated effect of implementing this measure
would be to reduce or eliminate inpatient anticoagulant dosing errors
that could lead to adverse drug events (ADEs) for patients with renal
impairment. Anticoagulants are one of three high risk drug classes
targeted in the National Action Plan for Adverse Drug Event Prevention.
Measure Specifications
- NQF Number (if applicable):
- Description: This eMeasure estimates the hospital-level,
risk-standardized rate of unplanned, all-cause readmission after
admission for any eligible condition within 30 days of hospital
discharge (RSRR). The eMeasure reports a single summary RSRR, derived
from the volume-weighted results of five different models, one for
each of the following specialty cohorts (grouped by discharge
condition categories or procedure categories): surgery/gynecology,
general medicine, cardiorespiratory, cardiovascular, and neurology.
The eMeasure also indicates the hospital standardized risk
ratios (SRR) for each of these five specialty cohorts. This eMeasure
is a re-engineering of measure 1789, the Hospital-Wide All-Cause
Risk-Standardized Readmission Measure developed for patients 65 years
and older using Medicare claims. This reengineered measure uses
clinical data elements from patients’ electronic health records for
risk adjustment in addition to claims data.
- Numerator statement: The outcome for this measure is
unplanned all-cause 30-day readmission. We defined a readmission as
an inpatient admission to any acute care facility which occurs within
30 days of the discharge date of an earlier, eligible index
admission.
- Denominator statement: Admissions for patients: Who are
matched in the EHR/claims data; Enrolled in Medicare FFS; Aged 65 or
over; Discharged from non-federal acute care hospitals; Discharged
alive; Not transferred to an acute care facility; Enrolled in Part A
for 12 mo prior
- Exclusions: The measure excludes admissions for patients:
•Admitted to Prospective Payment System (PPS)-exempt cancer hospitals
Rationale: These hospitals care for a unique population of patients
that cannot reasonably be compared to patients admitted to other
hospitals •Without at least 30 days of post-discharge enrollment in
FFS Medicare Rationale: The 30-day readmission outcome cannot be
assessed in this group since claims data are used to determine
whether a patient was readmitted. •Discharged against medical advice
(AMA) Rationale: Providers did not have the opportunity to deliver
full care and prepare the patient for discharge. •Admitted for
primary psychiatric diagnoses Rationale: Patients admitted for
psychiatric treatment are typically cared for in separate psychiatric
or rehabilitation centers that are not comparable to acute care
hospitals. •Admitted for rehabilitation Rationale: These admissions
are not typically to an acute care hospital and are not for acute
care. •Admitted for medical treatment of cancer Rationale: These
admissions have a different mortality and readmission profile than
the rest of the Medicare population, and outcomes for these
admissions do not correlate well with outcomes for other admissions.
Patients with cancer admitted for other diagnoses or for
surgical treatment of their cancer remain in the measure.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Hybrid
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP ?encouraged further development
of this e-Measure version of the endorsed Hospital-Wide All-Cause
Readmissions Measure (HWR). MAP expressed caution that this measure
should contain proper risk adjustment and was supportive of using
clinical data to improve the risk adjustment model performance.
Further, the MAP noted that CMS should review for the empirical and
conceptual relationship between SDS factors and hospital-wide
readmissions, and seek endorsement on this version of the measure by
the relevant NQF standing committee. MAP noted that after review and
endorsement by the NQF Standing Committee, this measure should be
brought back to the MAP for further discussion.
- Public comments received: 3
Rationale for measure provided by HHS
Currently, the
Centers for Medicare & Medicaid Services (CMS) publicly reports
risk-standardized readmission rates (RSRRs) for several conditions,
including acute myocardial infarction (AMI), heart failure (HF),
pneumonia, and hip and knee arthroplasty. CMS has also developed hospital
readmission measures for stroke and chronic obstructive pulmonary disease
(COPD). While it is helpful to assess readmission rates for
specific groups of patients, these conditions account for only a small
proportion of total readmissions. In 2013, CMS began publicly reporting a
hospital-wide, all-condition readmission measure which provides a broader
assessment of the quality of care at hospitals. This measure, which uses
the same cohort and outcome definitions as the proposed eMeasure,
includes 93% of admissions to acute care non-federal hospitals of
Medicare Fee-for-Service patients over age 65 who are discharged alive to
the non-acute care setting. The measure captures 92% of
readmissions following eligible admissions. The proposed measure will
build on the hospital-wide readmission measure by using clinical data
elements derived from electronic health records (EHR), such as laboratory
test values and vital signs, to risk adjust for patient-level factors
that influence readmission. The proliferation of EHR systems and
standardization of extraction and reporting of clinical data for quality
measurement provide an opportunity to integrate these data into measures
of hospital performance. This effort is also responsive to the preference
expressed by the clinical community for the use of clinical data
to adjust for patients’ severity of illness in hospital outcome measures.
Measure Specifications
- NQF Number (if applicable):
- Description: This measure assesses the number of
nulliparous women with a term, singleton baby in a vertex position
who are delivered by a cesarean section. PC O2 is also 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
- Denominator statement: Nulliparous patients delivered of a
live term singleton newborn in vertex presentation
- Exclusions: Excluded Populations: ICD-10-CM Principal
Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple
gestations and other presentations as defined in Appendix A, Table
11.09 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 or UTD
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: EHR
- Measure type: Outcome
- Steward: The Joint Commission
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encouraged continued development
of a maternal/child health disparities sensitive outcome e-measure.
Members noted that this measure is included in the MAP Safety Family
of Measures and also under review for the Medicare and Medicaid EHR
Incentive Program for Hospitals and Critical Access Hospitals
program. The original specification is NQF-endorsed (0471 – PC-02
Cesarean Section); however this version of the measure is not fully
specified as an e-Measure and has not been reviewed as an e-Measure
for endorsement.
- Public comments received: 2
Rationale for measure provided by HHS
PC O2 is newly
specified for electronic health records. Rationale: The removal of any
pressure to not perform a cesarean birth has led to a skyrocketing of
hospital, state and national cesarean section (CS) rates. Some hospitals
now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant
outcomes that are just as good and better maternal outcomes (Gould et
al., 2004). There are no data that higher rates improve any outcomes,
yet the CS rates continue to rise. This measure seeks to focus attention
on the most variable portion of the CS epidemic, the term labor CS in
nulliparous women. This population segment accounts for the large
majority of the variable portion of the CS rate, and is the area most
affected by subjectivity. As compared to other CS measures, what is
different about NTSV CS rate (Low-risk Primary CS in first births) is
that there are clear cut quality improvement activities that can be done
to address the differences. Main et al. (2006) found that over 60% of the
variation among hospitals can be attributed to first birth labor
induction rates and first birth early labor admission rates. The results
showed if labor was forced when the cervix was not ready the outcomes
were poorer. Alfirevic et al. (2004) also showed that labor and
delivery guidelines can make a difference in labor outcomes. Many authors
have shown that physician factors, rather than patient characteristics or
obstetric diagnoses are the major driver for the difference in rates
within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et
al., 2003). The dramatic variation in NTSV rates seen in all populations
studied is striking according to Menacker (2006). Hospitals within a
state (Coonrod et al., 2008; California Office of Statewide Hospital
Planning and Development [OSHPD], 2007) and physicians within a hospital
(Main, 1999) have rates with a 3-5 fold variation. Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html.
Measure Specifications
- NQF Number (if applicable):
- Description: Median time from emergency department (ED)
arrival to provider evaluation for individuals triaged at the two
highest levels based on a five-level triage system (e.g., triaged as
“immediate” or “emergent”).
- Numerator statement: Measure Observation 1: Median time
(in minutes) from ED arrival to Qualified Provider Contact for
Emergency Department patients triaged with an acuity level of
"1-immediate". Measure Observation 2: Median time (in minutes) from
ED arrival to Qualified Provider Contact for Emergency Department
patients triaged with an acuity level of "2-emergent".
- Denominator statement: Measure Population: Any emergency
department encounter for which individuals with a triage score of
“1-Immediate” or "2-Emergent" based on a 5-level triage
system.
- Exclusions: ED visit for trauma
- HHS NQS Priority: Making Care Safer
- HHS Data Source: EHR
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP has previously stressed the
importance of ED throughput measures as important markers of
efficiency and safety which can dramatically impact patient
experience.This measure in particular would address severely ill
patients being admitted to the ED. The MAP encouraged continued
development of this e-measure it may have the potential to capture
important clinical data. This measure is also under review for the
Hospital Inpatient Quality Reporting program.
- Public comments received: 2
Rationale for measure provided by HHS
This is a new eCQM
that assesses a different aspect of ED provider care, and specifically
assesses provider timeliness to evaluation. The anticipated effect of
implementing this measure would be to reduce the time for high risk
patients to be seen by a physician in the emergency department and
thereby reduce adverse events (i.e., morbidity and mortality). High-risk
individuals are identified by assignment of the highest or most
urgent score from a valid triage system.
Measure Specifications
- NQF Number (if applicable): 0291
- Description: Percentage of patients transferred to another
healthcare facility whose medical record documentation indicated that
administrative information was communicated to the receiving facility
within prior to departure
- Numerator statement: Percentage of patients transferred to
another healthcare facility whose medical record documentation
indicated that administrative information was communicated to the
receiving facility prior to departure • Nurse communication with
receiving hospitals • Practitioner communication with receiving
practitioner or transfer coordinator[For reference, numerator for
endorsed measure in QPS: Percentage of patients transferred to
another healthcare facility whose medical record documentation
indicated that administrative and clinical information was
communicated to the receiving facility IN AN APPROPRIATE TIME FRAME•
EDTC-SUB 1 Administrative communication- Nurse to nurse
communication- Physician to physician communication• EDTC-SUB 2
Patient information- Name- Address- Age- Gender- Significant others
contact information- Insurance• EDTC-SUB 3 Vital signs- Pulse-
Respiratory rate- Blood pressure- Oxygen saturation- Temperature-
Glasgow score or other neuro assessment for trauma, cognitively
altered or neuro patients only• EDTC-SUB 4 Medication information-
Medications administered in ED- Allergies- Home medications•
EDTC-SUB 5 Physician or practitioner generated information- History
and physical- Reason for transfer and/or plan of care• EDTC-SUB 6
Nurse generated information- Assessments/interventions/response-
Sensory Status (formerly Impairments)- Catheters-
Immobilizations- Respiratory support- Oral limitations• EDTC-SUB 7
Procedures and tests- Tests and procedures done- Tests and procedure
results sent]
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility
- Exclusions: All emergency department patients not
discharged to another healthcare facility.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record, Prescription Drug Event Data Elements
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 3
Rationale for measure provided by HHS
Communication
problems are a major contributing factor to adverse events in hospitals,
accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care
physicians in the community (Kripalani S 2007), and between hospitals and
long term facilities (Cortes T 2004). The Joint Commission has adopted
National Patient Safety Goal #2, “Improve the Effectiveness of
Communication Among Caregivers.” Requirement 2E for this goal requires
| Advance Care Plan
(Program: Hospital Outpatient Quality Reporting Program;
MUC ID: E0326) |
Measure Specifications
- NQF Number (if applicable): 0326
- Description: Percentage of patients aged 65 years and
older who have an advance care plan or surrogate decision maker
documented in the medical record or documentation in the medical
record that an advance care plan was discussed but the patient did
not wish or was not able to name a surrogate decision maker or
provide an advance care plan. [Description differs from posted MUC
list based on NQF staff analysis]
- Numerator statement: Patients who have an advance care
plan or surrogate decision maker documented in the medical record or
documentation in the medical record that an advance care plan was
discussed but patient did not wish or was not able to name a
surrogate decision maker or provide an advance care plan. [Numerator
differs from posted MUC list based on NQF staff
analysis]
- Denominator statement: All patients aged 65 years and
older.
- Exclusions: None
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Administrative Claims, EHR
- Measure type: Process
- Steward: National Committee for Quality Assurance
- Endorsement Status: Endorsed
Summary of workgroup deliberations: Consensus not reached. No
Decision. Vote Result: 39% Support; 17% Conditional Support; 43% Do Not
Support. This measure was extensively discussed by the MAP Hospital
workgroup members and ultimately they were not able to reach consensus on
the disposition of this measure. The workgroup agreed to send this
measure to the MAP Coordinating Committee for further discussion and
final decision. The group did take a straw poll vote to provide the
Coordinating Committee with a preliminary assessment of the workgroup.
The members of the workgroup broadly agreed on the importance of an
advanced care plan. Some members urged that every opportunity to discuss
advanced directives needs to be taken and that all providers have a
responsibility to have these conversations, including outpatient
facilities. Others argued that these conversations require an ongoing
provider and patient relationship and it is under that context where
these conversations are most appropriate. Further, others argued that
the measure as specified is a simple check the box measure and does
not have the potential to truly improve patient care.
Public comments received: 6
Preliminary Analysis of Measure
- Preliminary analysis result: Support
- Preliminary analysis summary: This measure addresses an
important aspect of patient engagement, promotes alignment across
programs, and is NQF-endorsed.
- Does the measure address a critical program objective as
defined by MAP? Yes. This measure is highly impactful and
meaningful to patients that is used in multiple public programs and
fulfills many ambulatory measurement gaps such patient and family
engagement and follow-up after procedures. Advance care planning
(ACP) is an itera
- Measure development status: Fully developed
- Is the measure fully tested for the program's setting and
level of analysis? Yes. This measure has been tested in the
ambulatory setting.
- Is the measure currently in use? Yes. This measure
supports alignment across programs by currently being used in several
federal programs, filling the measurement gaps in the ambulatory
setting of patient and family engagement and follow-up after
procedures, and being part of multiple NQF Families of Measures, such
as Care Coordination, Dual Eligible Beneficiaries, and
Hospice.
- 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.
- Does the measure address a high-priority quality issue in
the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS
This measure would be
consistent with a legislative mandate affecting Medicare beneficiaries,
the Patient Self Determination Act (PSDA), approved in 1990. The act
requires that beneficiaries be informed about their rights to
self-determination and the use of advance directives, and identifies
particular facilities accountable for providing the information. Despite
this, a recent cancer research study had found that most patients had not
spoken extensively to health professionals or close persons about the
future. Furthermore, a recent meta-analysis found that awareness of
patients´ and surrogates´ decision-making characteristics and
communication styles can help clinicians identify potential barriers and
variations in patterns of communication. To that end, the authors
contend that initial and ongoing assessments of patients´ and surrogates´
communication style and characteristics must be incorporated into the
plan of care (Melhado 2011). A cross-sectional study out of Oklahoma
found that among community dwelling older persons, a living will is a
positive first step towards healthcare planning and designating a
power of attorney. They also found that the state’s effort to increase
the use of advance directives among older residents was successful,
indicating that organizations have the power to influence people with
respect ACP (Mcauley 2008). An observational study from La Crosse County,
Wisconsin found that a system for ACP can be managed in a geographic
region so that, at the time of death, almost all adults have an advance
care plan that is specific and available and treatment is consistent
with their plan. The data from this study suggest that quality efforts
have improved the prevalence, clarity, and specificity of ACPs (Hammes
2010). Barnes KA, Barlow CA, Harrington J, Ornadel K, Tookman A, King M,
& Jones L. (2011). Advance Care Planning Discussions in Advanced
Cancer: Analysis of Dialogues Between Patients and Care Planning
Mediators. Palliative & Supportive Care;9(1):73-9. Basanta WE.
(2002). Advance Directives and Life-Sustaining Treatment: A Legal
Primer. Hematology/Oncology Clinics of North America;16(6):1381-96.
Garand L, Drew MA, Lingler JH, & DeKosky ST. (2011). Incidence and
Predictors of Advance Care Planning Among Persons With Cognitive
Impairment. American Journal of Geriatric Psychiatry;18(8):712-20. Hammes
BJ, Rooney BL, & Gundrum JD. (2010). A Comparative, Retrospective,
Observational Study of the Prevalence, Availability, and Specificity
of Advance Care Plans in a County that Implemented an Advance Care
Planning Microsystem. Journal of the American Geriatrics
Society;58(7):1249-55. Mcauley WJ, McCutheon ME, & Travis SS. (2008).
Advance Directives for Health Care Among Older Community Residents.
Journal of Health & Human Services Administration, 30(4), 402-419.
Melhado LW & Byers JF. (2011). Patients’ and Surrogates’
Decision-Making Characteristics Withdrawing, Withholding, and Continuing
Life-Sustaining Treatments. Journal of Hospice & Palliative
Nursing;13(1):16-28. Sampson EL, Jones L, Thune-Boyle IC, Kukkastenvehmas
R, King M, Leurent B, Tookman A, & Blanchard MR. Palliative
assessment and advance care planning in severe dementia: An exploratory
randomized controlled trial of a complex intervention. Palliative
Care;25(3):197-209. Sanders A, Schepp M, & Baird M. (2011). Partial
do-not-resuscitate orders: A Hazard to Patient Safety and Clinical
Outcomes? Critical Care Medicine;39(1):14-8. Tung EE, Vickers KS, Lackore
K, Cabanela R, Hathaway J, & Chaudhry R. (2011). Clinical
Decision Support Technology to Increase Advance Care Planning in the
Primary Care Setting. American Journal of Hospice and Palliative
Medicine;28(4):230-5.
Measure Specifications
- NQF Number (if applicable): 1822
- Description: This measure reports the percentage of
patients, regardless of age, with a diagnosis of painful bone
metastases and no history of previous radiation who receive external
beam radiation therapy (EBRT) with an acceptable fractionation scheme
as defined by the guideline.
- Numerator statement: All patients, regardless of age, with
painful bone metastases, and no previous radiation to the same
anatomic site who receive EBRT with any of the following recommended
fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns,
8Gy/1fxn.
- Denominator statement: All patients with painful bone
metastases and no previous radiation to the same anatomic site who
receive EBRT
- Exclusions: The medical reasons for denominator exclusions
are: 1) Previous radiation treatment to the same anatomic site; 2)
Patients with femoral axis cortical involvement greater than 3 cm in
length; 3) Patients who have undergone a surgical stabilization
procedure; and 4) Patients with spinal cord compression, cauda equina
compression or radicular pain
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: EHR, Paper Medical Record
- Measure type: Process
- Steward: American Society for Radiation Oncology
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: External beam radiation can help
provide patients with pain relief. MAP noted that this measure has a
demonstrated performance gap and would begin to expand cancer care
measurement to settings beyond the PPS-exempt cancer hospitals.
However, MAP encouraged the adoption of additional cancer care
measures for the OQR program, nothing that this measure would not be
enough to raise the standard of care or help consumers make informed
choices on its own.
- Public comments received: 1
Rationale for measure provided by HHS
The measure is
developed from the recommendations by the clinical-practice guideline.
This measure is intended to close the gap in the demonstrated treatment
variation and ensure the use of an appropriate fractionation schedule.
The measure also takes into account the effective schedule for relieving
pain from bone metastases, patient preferences and the time and cost
effectiveness. Population: The measure is applicable to all patients,
regardless of age with a diagnosis of painful bone metastases who are
prescribed EBRT unless there is a documented exclusion as specified. 1.
Jeremic B, Shibamoto Y, Acimovic L, et al. A randomized trial of three
single-dose radiation therapy regimens in the treatment of metastatic
bone pain. Int J Radiat Oncol Biol Phys 1998;42:161–167. 2. Bone Pain
Trial Working Party. 8 Gy single fraction radiotherapy for the treatment
of metastatic skeletal pain: Randomized comparison with a
multifraction schedule over 12 months of patient follow-up. Radiother
Oncol 1999;52:111–121. 3. Roos D, Turner S, O’Brien P, et al. Randomized
trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for
neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology
Group, TROG 96.05). Radiother Oncol 2005;75: 54–63. 4. Hartsell W, Konski
A, Scott C, et al. Randomized trial of short versus long-course
radiotherapy for palliation of painful bone metastases. J Natl Cancer
Inst 2005;97:798–804.
Measure Specifications
- NQF Number (if applicable): 1898
- Description: 100 measure of health literacy related to
patient-centered communication, derived from items on the staff and
patient surveys of the Communication Climate Assessment
Toolkit
- Numerator statement: Health literacy component of
patient-centered communication: an organization should consider the
health literacy level of its current and potential populations and
use this information to develop a strategy for the clear
communication of medical information verbally, in writing and using
other media. Measure is scored based on 15 items from the patient
survey of the C-CAT and 13 items from the staff survey of the C-CAT.
Minimum of 100 patient responses and 50 staff responses.
- Denominator statement: There are two components to the
target population: staff (clinical and nonclinical) and patients.
Sites using this measure must obtain at least 50 staff responses and
at least 100 patient responses.
- Exclusions: Staff respondents who do not have direct
contact with patients are excluded from questions that specifically
address patient contact.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Outcome
- Steward: American Medical Association
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP noted that this measure would
address an important aspect of patient and family engagement and is
of particular importance to consumers, especially dual eligible
beneficiaries. MAP members stressed the importance of culture change
and the need to understand if communications are appropriately
directed to patients. Studies have shown that better scores on
measures of health literacy are correlated with import indicators of
healthcare quality. Some members of the MAP expressed caution that
that while health literacy is an important area for measurement,
Hospital Outpatient environments may not be the appropriate locus of
accountability. Additionally some members raised concerns
about the burden of implementing survey measures.
- Public comments received: 4
Rationale for measure provided by HHS
Evidence generated
through national validation study of C-CAT instrument, including surveys
of patients and staff. Results of study demonstrated that better scores
on the measure of health literacy is correlated to important indicators
of health care quality. Multivariate analysis showed that a 5-point
increase in the measure results in more than a 1/3 greater odds that
patients would report receiving high-quality medical care (OR 1.40, 95%
CI 1.22-1.61) and a more than 25% greater odds that patients would report
a belief that their medical records are kept private (OR 1.28, 95% CI
1.10-1.47). Likewise, a 5-point increase in the measure score is
correlated with a more than 25% decrease in the odds a patient would
believe that a mistake made in their care would be hidden from them (OR
0.73, 95% CI 0.62-0.86). Additional evidence of the importance of health
literacy to patient-centered communication from Improving
Communication -- Improving Care: How Health Care Organizations Can Ensure
Effective, Patient-Centered Communication with People from Diverse
Populations.
http://www.ama-assn.org/resources/doc/ethics/pcc-consensus-report.pdf
Measure Specifications
- NQF Number (if applicable): 0293
- Description: Percentage of patients transferred to another
HEALTHCARE FACILITY whose medical record documentation indicated that
medication information was communicated to the receiving FACILITY
within 60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another HEALTHCARE FACILITY whose medical record documentation
indicated that medication information was communicated to the
receiving FACILITY within 60 minutes of departure • Documentation
regarding medication history • Allergies • Medications given
(MAR)
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility
- Exclusions: All emergency department patients not
discharged to another healthcare facility.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record, Prescription Drug Event Data Elements
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 4
Rationale for measure provided by HHS
Patient safety
studies have identified the Emergency Department as the location within a
hospital that has the highest percentage of preventable and negligent
adverse events.1-2 Increasing attention is being paid to prevention of
medical errors in Emergency Department settings, but considerable work
still needs to be done to develop performance measures for Emergency
Department care.3-4 Patients who are transferred from an Emergency
Department to another facility are excluded from the calculation of most
national quality measures, such as the Hospital Compare measures. In
addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient
transfers between Emergency Departments and other facilities. This type
of measure is important for all healthcare facilities, but is especially
important for small rural hospitals, which transfer a higher
proportion of Emergency Department patients to other facilities than do
larger urban facilities.5-9 1. Leape, L., Brennan, T., Laird, N. et al.
The Nature of Adverse Events in Hospitalized Patients. Results of the
Harvard Medical Practice Study II. New England Journal of Medicine
324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et al.
Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance
Measures and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004. 8. Baldwin LM, MacLehose RF, Hart LG et al.
Quality of care for acute myocardial infarction in rural and urban US
hospitals. Journal of Rural Health, 20:99-108, 2004. 9. Westfall JM, Van
Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in
rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at:
http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July
18, 2007. 11. Kripalani, S., LeFevre, F., Phillips, C. et al. Deficits in
Communication and Information Transfer between Hospital-Based and Primary
Care Physicians: Implications for Patient Safety and Continuity of Care.
JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and Fitzpatrick
J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004. 13. Joint Commission on Accreditation of
Healthcare Organizations. 2008 National Patient Safety Goals. Available
at: http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18, 2007.
Measure Specifications
- NQF Number (if applicable): 0296
- Description: Percentage of patients transferred to another
HEALTHCARE FACILITY whose medical record documentation indicated that
nursing information was communicated to the receiving FACILITY within
60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another healthcare facility whose medical record documentation
indicated that nursing information was communicated to the receiving
facility within 60 minutes of departure • Assessments/
intervention/response • Impairments • Catheters • Immobilizations •
Respiratory support • Oral limitations
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility
- Exclusions: All emergency department patients not
discharged to another healthcare facility
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: EHR, Paper Medical Record, Prescription
Drug Event Data Elements
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 3
Rationale for measure provided by HHS
Patients who are
transferred from an Emergency Department to another acute facility are
excluded from the calculation of most national quality measures, such as
the Hospital Compare measures. In addition, limited attention has been
paid to the development and implementation of quality measures
specifically focused on patient transfers between Emergency Departments
and other facilities. This type of measure is important for all
healthcare facilities, but is especially important for small rural
hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD
2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM
2006). Communication problems are a major contributing factor to adverse
events in hospitals, accounting for 65% of sentinel events tracked by the
Joint Commission (JCAHO 2007). In addition, research indicates that
deficits exist in the transfer of patient information between hospitals
and primary care physicians in the community (Kripalani S 2007), and
between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this
goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician
hand-offs from the emergency department to inpatient units, other
hospitals, and other types of health care facilities. The process must
include a method of communicating up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or
anticipated changes (JCAHO-2 2007). 1. Leape, L., Brennan, T., Laird, N.
et al. The Nature of Adverse Events in Hospitalized Patients. Results of
the Harvard Medical Practice Study II. New England Journal of
Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et
al. Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance Measures
and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004.
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: "When you arrived at
this facility on the day of your procedure, did the check-in process
run smoothly?" P2: "Was the facility clean?" P3: "Were the clerks and
receptionists at the facility as helpful as you thought they should
be?" P4: "Did the clerks and receptionists at the facility treat you
with courtesy and respect?" P5: "Did the doctors, nurses and other
staff treat you with courtesy and respect?" P6: "Did the doctors,
nurses and other staff make sure you were as comfortable as
possible?"
- Numerator statement: Proportions of top box responses
(YES) are calculated for each question. The proportions are then
averaged over all questions in the multi-item measure.
(P1+P2+P3+P4+P5+P6)/6
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: CMS requested that MAP consider these
five Outpatient/Ambulatory Surgery Patient Experience of Care Survey
(O/ASPECS) measure components as a set. This patient-reported outcome
outpatient/ambulatory surgery patient experience of care survey asks
five specific questions regarding the communication of discharge
instructions and follow-up after discharge. The MAP noted that this
is a high impact measure that will improve both quality and
efficiency of care and be meaningful to consumers. Given that this
measure is also under consideration for the Ambulatory Surgical
Center Quality Reporting program, this measure helps to promote
alignment across care settings. This measure would begin to fill a
gap MAP has previously identified for this program including patient
reported outcomes and patient and family engagement. Several
workgroup members noted that CMS should consider how this measure is
related to other existing ambulatory survey to ensure that patients
and facilities aren't overburdened.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: “Did your doctor or
anyone from the facility give you all the information you needed
about your procedure?” P2: “Did your doctor or anyone from the
facility give you easy to understand instructions about getting ready
for your procedure?” P3: “Did the doctors, nurses and other staff
explain things about your procedure in a way that was easy for you to
understand?” P4 “Did your doctor or anyone from the facility explain
the process of giving anesthesia in a way that was easy to
understand? P5: “Did your doctor or anyone from the facility explain
the possible side effects of the anesthesia in a way that was easy
to understand?
- Numerator statement: Proportions of top box responses
(YES, YES DEFINITELY) are calculated for each question. P4 and P5
count only those who had anesthesia. These proportions are then
averaged over all questions in the multi-item measure. (P1 + P2 + P3
+ P4 + P5)/5
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: CMS requested that MAP consider these
five Outpatient/Ambulatory Surgery Patient Experience of Care Survey
(O/ASPECS) measure components as a set. This patient-reported outcome
outpatient/ambulatory surgery patient experience of care survey asks
five specific questions regarding the communication of discharge
instructions and follow-up after discharge. The MAP noted that this
is a high impact measure that will improve both quality and
efficiency of care and be meaningful to consumers. Given that this
measure is also under consideration for the Ambulatory Surgical
Center Quality Reporting program, this measure helps to promote
alignment across care settings. This measure would begin to fill a
gap MAP has previously identified for this program including patient
reported outcomes and patient and family engagement. Several
workgroup members noted that CMS should consider how this measure is
related to other existing ambulatory survey to ensure that patients
and facilities aren't overburdened.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Multi-item measure: P1: “Discharge
instructions include things like symptoms you should watch out for
after your procedure, instructions about your medicines, and home
care. Before you left the facility, did you receive written discharge
instructions?” P2: “Did your doctor or anyone from the facility
prepare you for what to expect during your recovery?” P3: “Ways to
control pain can include prescription medicine, over-the-counter pain
relievers or ice packs, for example. Did your doctor or anyone from
the facility give you information about what to do if you had pain
as a result of your procedure” (of those that had pain as a
result of the procedure). P4: “Before you left, did your doctor or
anyone from the facility give you information about what to do if you
had nausea or vomiting” (of those that had either nausea or vomiting
as a result of either your procedure or anesthesia). P5: “Before you
left, did your doctor or anyone from the facility give you
information about what to do if you had bleeding as a result of your
procedure” (of those that had bleeding as a result of the procedure).
P6: “Possible signs of infection include fever, swelling, heat,
drainage or redness. Before you left, did your doctor or anyone from
the facility give you information about what to do if you had
possible signs of infection (of those having signs of infection as a
result of the procedure).
- Numerator statement: Proportions of top box responses
(YES, YES DEFINITELY) are calculated for each question. These
proportions are then averaged over all questions in the multi-item
measure. (P1 + P2 + P3 + P4 + P5+ P6)/6
- Denominator statement: See numerator statement.
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: CMS requested that MAP consider these
five Outpatient/Ambulatory Surgery Patient Experience of Care Survey
(O/ASPECS) measure components as a set. This patient-reported outcome
outpatient/ambulatory surgery patient experience of care survey asks
five specific questions regarding the communication of discharge
instructions and follow-up after discharge. The MAP noted that this
is a high impact measure that will improve both quality and
efficiency of care and be meaningful to consumers. Given that this
measure is also under consideration for the Ambulatory Surgical
Center Quality Reporting program, this measure helps to promote
alignment across care settings. This measure would begin to fill a
gap MAP has previously identified for this program including patient
reported outcomes and patient and family engagement. Several
workgroup members noted that CMS should consider how this measure is
related to other existing ambulatory survey to ensure that patients
and facilities aren't overburdened.
- Public comments received: 2
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable):
- Description: Survey Question: Using any number from 0 10
10, where 0 is the worst facility possible and 10 is the best
facility possible, what number would you use to rate this
facility?
- Numerator statement: Number of respondents answering 9 or
10
- Denominator statement: Number of respondents answering the
survey question
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: CMS requested that MAP consider these
five Outpatient/Ambulatory Surgery Patient Experience of Care Survey
(O/ASPECS) measure components as a set. This patient-reported outcome
outpatient/ambulatory surgery patient experience of care survey asks
five specific questions regarding the communication of discharge
instructions and follow-up after discharge. The MAP noted that this
is a high impact measure that will improve both quality and
efficiency of care and be meaningful to consumers. Given that this
measure is also under consideration for the Ambulatory Surgical
Center Quality Reporting program, this measure helps to promote
alignment across care settings. This measure would begin to fill a
gap MAP has previously identified for this program including patient
reported outcomes and patient and family engagement. Several
workgroup members noted that CMS should consider how this measure is
related to other existing ambulatory survey to ensure that patients
and facilities aren't overburdened.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
| O/ASPECS Recommend
(Program: Hospital Outpatient Quality Reporting Program;
MUC ID: X3703) |
Measure Specifications
- NQF Number (if applicable):
- Description: Survey question: Would you recommend this
facility to your friends and family? Response options: Definately no,
Probably no, Probably yes, Definately yes.
- Numerator statement: Number of respondents answering
“Definately yes”.
- Denominator statement: Number of respondents answering the
survey question
- Exclusions: Persons younger than 18 years having a surgery
or procedure in a hospital outpatient surgery department or
ambulatory surgery center, CPT code does not fall between
100021-69990 without Modifier 53 (procedure did not take place);
discharged to hospice.
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: Survey
- Measure type: Patient Engagement/Experience
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: CMS requested that MAP consider these
five Outpatient/Ambulatory Surgery Patient Experience of Care Survey
(O/ASPECS) measure components as a set. This patient-reported outcome
outpatient/ambulatory surgery patient experience of care survey asks
five specific questions regarding the communication of discharge
instructions and follow-up after discharge. The MAP noted that this
is a high impact measure that will improve both quality and
efficiency of care and be meaningful to consumers. Given that this
measure is also under consideration for the Ambulatory Surgical
Center Quality Reporting program, this measure helps to promote
alignment across care settings. This measure would begin to fill a
gap MAP has previously identified for this program including patient
reported outcomes and patient and family engagement. Several
workgroup members noted that CMS should consider how this measure is
related to other existing ambulatory survey to ensure that patients
and facilities aren't overburdened.
- Public comments received: 1
Rationale for measure provided by HHS
Patient experience of
care measures are a CMS priority
Measure Specifications
- NQF Number (if applicable): 0294
- Description: Percentage of patients transferred to another
HEALTHCARE FACILITY whose medical record documentation indicated that
patient information was communicated to the receiving FACILITY within
60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another HEALTHCARE FACILITY whose medical record documentation
indicated that patient information was communicated to the receiving
FACILITY within 60 minutes of departure • Patient name • Address •
Date of birth • Gender • Significant other contact information •
Health insurance information
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility
- Exclusions: All emergency department patients not
discharged to another healthcare facility
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 2
Rationale for measure provided by HHS
Patients who are
transferred from an Emergency Department to another acute facility are
excluded from the calculation of most national quality measures, such as
the Hospital Compare measures. In addition, limited attention has been
paid to the development and implementation of quality measures
specifically focused on patient transfers between Emergency Departments
and other facilities. This type of measure is important for all
healthcare facilities, but is especially important for small rural
hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD
2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM
2006). Communication problems are a major contributing factor to adverse
events in hospitals, accounting for 65% of sentinel events tracked by the
Joint Commission (JCAHO 2007). In addition, research indicates that
deficits exist in the transfer of patient information between hospitals
and primary care physicians in the community (Kripalani S 2007), and
between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this
goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician
hand-offs from the emergency department to inpatient units, other
hospitals, and other types of health care facilities. The process must
include a method of communicating up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or
anticipated changes (JCAHO-2 2007). 1. Leape, L., Brennan, T., Laird, N.
et al. The Nature of Adverse Events in Hospitalized Patients. Results of
the Harvard Medical Practice Study II. New England Journal of
Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et
al. Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance Measures
and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004. 8. Baldwin LM, MacLehose RF, Hart LG et al.
Quality of care for acute myocardial infarction in rural and urban US
hospitals. Journal of Rural Health, 20:99-108, 2004. 9. Westfall JM, Van
Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in
rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at:
http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July
18, 2007. 11. Kripalani, S., LeFevre, F., Phillips, C. et al. Deficits in
Communication and Information Transfer between Hospital-Based and Primary
Care Physicians: Implications for Patient Safety and Continuity of Care.
JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and Fitzpatrick
J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004.
Measure Specifications
- NQF Number (if applicable): 0295
- Description: Percentage of patients transferred to another
HEALTHCARE FACILITY whose medical record documentation indicated that
physician information was communicated to the receiving FACILITY
within 60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another HEALTHCARE FACILITY whose medical record documentation
indicated that physician information was communicated to the
receiving FACILITY within 60 minutes of departure • Physician or
practitioner history and physical • Physician or practitioner orders
and plan
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility
- Exclusions: All emergency department patients not
transferred to another healthcare facility
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 3
Rationale for measure provided by HHS
Patients who are
transferred from an Emergency Department to another acute facility are
excluded from the calculation of most national quality measures, such as
the Hospital Compare measures. In addition, limited attention has been
paid to the development and implementation of quality measures
specifically focused on patient transfers between Emergency Departments
and other facilities. This type of measure is important for all
healthcare facilities, but is especially important for small rural
hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD
2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM
2006). Communication problems are a major contributing factor to adverse
events in hospitals, accounting for 65% of sentinel events tracked by the
Joint Commission (JCAHO 2007). In addition, research indicates that
deficits exist in the transfer of patient information between hospitals
and primary care physicians in the community (Kripalani S 2007), and
between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this
goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician
hand-offs from the emergency department to inpatient units, other
hospitals, and other types of health care facilities. The process must
include a method of communicating up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or
anticipated changes (JCAHO-2 2007). 1. Leape, L., Brennan, T., Laird, N.
et al. The Nature of Adverse Events in Hospitalized Patients. Results of
the Harvard Medical Practice Study II. New England Journal of
Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et
al. Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance Measures
and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004. 8. Baldwin LM, MacLehose RF, Hart LG et al.
Quality of care for acute myocardial infarction in rural and urban US
hospitals. Journal of Rural Health, 20:99-108, 2004. 9. Westfall JM, Van
Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in
rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at:
http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July
18, 2007. 11. Kripalani, S., LeFevre, F., Phillips, C. et al. Deficits in
Communication and Information Transfer between Hospital-Based and Primary
Care Physicians: Implications for Patient Safety and Continuity of Care.
JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and Fitzpatrick
J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004.
Measure Specifications
- NQF Number (if applicable): 0297
- Description: Percentage of patients transferred to another
healthcare facility whose medical record documentation indicated that
procedure and test information was communicated to the receiving
FACILITY within 60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another Healthcare Facility whose medical record documentation
indicated that procedure and test information was communicated to the
receiving FACILITY within 60 minutes of departure • Tests &
procedures done • Tests & procedure results sent
- Denominator statement: All emergency department patients
who are transferred to another Healthcare Facility
- Exclusions: ED admissions not transferred to another
Healthcare facility.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record, Prescription Drug Event Data Elements
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 3
Rationale for measure provided by HHS
Patients who are
transferred from an Emergency Department to another acute facility are
excluded from the calculation of most national quality measures, such as
the Hospital Compare measures. In addition, limited attention has been
paid to the development and implementation of quality measures
specifically focused on patient transfers between Emergency Departments
and other facilities. This type of measure is important for all
healthcare facilities, but is especially important for small rural
hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD
2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM
2006). Communication problems are a major contributing factor to adverse
events in hospitals, accounting for 65% of sentinel events tracked by the
Joint Commission (JCAHO 2007). In addition, research indicates that
deficits exist in the transfer of patient information between hospitals
and primary care physicians in the community (Kripalani S 2007), and
between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this
goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician
hand-offs from the emergency department to inpatient units, other
hospitals, and other types of health care facilities. The process must
include a method of communicating up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or
anticipated changes (JCAHO-2 2007). 1. Leape, L., Brennan, T., Laird, N.
et al. The Nature of Adverse Events in Hospitalized Patients. Results of
the Harvard Medical Practice Study II. New England Journal of
Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et
al. Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance Measures
and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004.
Measure Specifications
- NQF Number (if applicable):
- Description: This measure calculates the percentage of
Emergency Department (ED) visits for atraumatic headache with a
coincident brain computed tomography (CT) study for Medicare
beneficiaries.
- Numerator statement: Of ED visits identified in the
denominator, visits with a coincident brain CT study (i.e., brain CT
studies on the same day for the same patient).
- Denominator statement: ED patients with a primary
diagnosis of atraumatic headache.
- Exclusions: This measure uses exceptions from the
numerator, rather than exclusions from the denominator The following
secondary diagnosis codes are exceptions from the numerator:
-Anticoagulant use -Lumbar puncture -Dizziness or paresthesia -Lack
of coordination -Subarachnoid hemorrhage -Complicated or thunderclap
headache -Focal neurologic deficit -Pregnancy -Trauma -HIV
-Tumor(s)/mass(es) -Imaging studies for ED patients admitted to the
hospital"
- HHS NQS Priority: Making Care Affordable
- HHS Data Source: Administrative Claims
- Measure type: Efficiency
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Conditional support pending NQF
endorsement. The MAP reviewed an update to the existing measure
currently in the OQR program but public reporting has been postponed.
Workgroup members noted that this measure would help to improve
efficiency and reduce unnecessary utilization of imaging in the ED
for patients presenting with an atraumatic headache where the
clinical value of imaging appears limited. However, other members
noted concerns with the current measure specifications noting
limiting with using administrative claims data, and the exclusions in
the measure. The Workgroup concluded that improved measure
specifications for this measure and review and endorsement by an NQF
Standing Committee could address technical concerns.
- Public comments received: 5
Rationale for measure provided by HHS
Development of
efficiency measures is one of the primary objectives highlighted by both
the 2012 report on the National Quality Strategy and the Centers for
Medicare & Medicaid Services (CMS). This measure's concept is similar
to one which was identified within the 2011 release of the Choosing
Wisely campaign recommendations as an area of concern. Moreover, there
is evidence that diagnostic imaging for headaches is overused, with
only 2% of patient scans yielding pathology. Unnecessary imaging is
costly and needlessly exposes patients to radiation.
| Vital Signs
(Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0292) |
Measure Specifications
- NQF Number (if applicable): 0292
- Description: Percentage of patients transferred to another
HEALTHCARE FACILITY whose medical record documentation indicated that
the entire vital signs record was communicated to the receiving
FACILITY within 60 minutes of departure
- Numerator statement: Percentage of patients transferred to
another healthcare facility whose medical record documentation
indicated that the entire vital signs record was communicated to the
receiving facility within 60 minutes of departure • Pulse •
Respiratory rate • Blood pressure • Oxygen saturation • Temperature •
Glasgow score (where appropriate)
- Denominator statement: All emergency department patients
who are transferred to another healthcare facility.
- Exclusions: All emergency department patients not
discharged to another healthcare facility.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims, EHR, Paper Medical
Record, Prescription Drug Event Data Elements
- Measure type: Process
- Steward: University of Minnesota Rural Health Research
Center
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to support this
measure conditional on condensing the components into one measure and
endorsement as one comprehensive measure. This measure would help to
address a previously identified gap around improving care
coordination and would help ensure vital information is transferred
between sites of care. These measures are the Emergency Department
Transfer Communication Measure set which consists of seven components
that focus on communication between facilities around the transfer of
patients. The measure set assists in filling the workgroup
identified priority gap of enhancing care coordination efforts. After
the Hospital Workgroup meeting, the measure developer clarified that
the measure has been updated to include all the components in a
comprehensive measure. The Coordinating Committee will be asked to
consider supporting this measure without conditions.
- Public comments received: 4
Rationale for measure provided by HHS
Patients who are
transferred from an Emergency Department to another acute facility are
excluded from the calculation of most national quality measures, such as
the Hospital Compare measures. In addition, limited attention has been
paid to the development and implementation of quality measures
specifically focused on patient transfers between Emergency Departments
and other facilities. This type of measure is important for all
healthcare facilities, but is especially important for small rural
hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD
2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM
2006). Communication problems are a major contributing factor to adverse
events in hospitals, accounting for 65% of sentinel events tracked by the
Joint Commission (JCAHO 2007). In addition, research indicates that
deficits exist in the transfer of patient information between hospitals
and primary care physicians in the community (Kripalani S 2007), and
between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this
goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician
hand-offs from the emergency department to inpatient units, other
hospitals, and other types of health care facilities. The process must
include a method of communicating up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or
anticipated changes (JCAHO-2 2007). 1. Leape, L., Brennan, T., Laird, N.
et al. The Nature of Adverse Events in Hospitalized Patients. Results of
the Harvard Medical Practice Study II. New England Journal of
Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et
al. Incidence and Types of Adverse Events and Negligent Care in Utah and
Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments.
Academic Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine,
J., Camago, C. and Reese, C. Emergency Department Performance Measures
and Benchmarking Summit. Academic Emergency Medicine,
13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges JR.
Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization
and interhospital transfers as potential indicators of rural hospital
quality. Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF,
Bhimaraj A, Perpich D. Organization of care for acute myocardial
infarction in rural and urban hospitals in Kansas. Journal of Rural
Health. 20:363-367, 2004. 8. Baldwin LM, MacLehose RF, Hart LG et al.
Quality of care for acute myocardial infarction in rural and urban US
hospitals. Journal of Rural Health, 20:99-108, 2004. 9. Westfall JM, Van
Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in
rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at:
http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July
18, 2007. 11. Kripalani, S., LeFevre, F., Phillips, C. et al. Deficits in
Communication and Information Transfer between Hospital-Based and Primary
Care Physicians: Implications for Patient Safety and Continuity of Care.
JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and Fitzpatrick
J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004.
Measure Specifications
- NQF Number (if applicable):
- Description: Number of hospital-specific 30-day
unscheduled and potentially avoidable readmissions following
hospitalization among diagnosed malignant cancer patients
- Numerator statement: Total number of unscheduled
readmissions within 30 days of index admission
- Denominator statement: Total PPS-Exempt Cancer Center
admissions within the reporting year for patients [aged 18+]
discharged alive from the facility with an active malignant cancer
diagnosis
- Exclusions: Numerator Exclusions: Medical exclusions (1P)
only are permitted for this measure, for example, patients who
develop metastatic disease progression and/or planned therapy (for
example chemotherapy) Denominator Exclusions: 1. Patients readmitted
to another acute care center Rationale: Full data for admissions
outside of index facility may be unavailable. This also includes
admissions for primary diagnoses of psychiatric disease (cared for in
separate psychiatric or rehabilitation centers and do not
compare to acute care facilities). 2. Patients that left Against
Medical Advice in the index admission Rationale: Hospital had limited
opportunity to implement high quality care. 3. Patients that were
transferred to Another Acute Care facility in the index admission
Rationale: This does not capture the target population of patients
who may benefit from the specifications of the measure. 4. Admissions
for patients without 30 days of post-discharge data Rationale: This
is necessary in order to identify readmissions in the dataset. 5.
Admissions for patients without a complete enrollment history
for the 12 months prior to admission Rationale: This is necessary to
capture historical data for (pending) risk adjustment.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Clinical Data
- Measure type: Outcome
- Steward: Alliance of Dedicated Cancer Centers
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP was conditionally supportive of
this measure pending NQF review and endorsement. MAP noted that this
is a critically important area for measurement and with appropriate
harmonization of existing readmission measures, this measure can help
drive alignment across facilities.
- Public comments received: 5
Rationale for measure provided by HHS
Readmission rates can
be used as a source of both quality improvement and cost containment,
contributing to the triple aim of the Patient Protection and Affordable
Care Act; better health, better care, and lower healthcare costs for
patients. The many facets and subsequent variation of readmissions across
facilities demonstrate the need for a standardized methodology of
data collection. Moreover, differentiation between organic disease and
complications (potentially requiring reoperation) is necessary to
accurately determine quality of care (Brown et al.). The proposed measure
addresses a cancer-specific patient population, specified for PPS-Exempt
Cancer Centers operating within the United States. The reduction in
variability for patient diagnoses as well as care setting promotes the
development of an optimized measure to yield the greatest benefit to
patients (i.e., one that has been specified for their unique
conditions/diagnoses). For the purpose of this measure, “costs” should
be understood to comprehensively include 1. The physiologic, psychologic,
and monetary detriment to the patient 2. Financial cost to the
institution, and 3. Potential cost to the practicing surgeon (when higher
readmission rates are used as surrogates for substandard care in quality
improvement circles) (Brown et al). The outcome measured counts the
number of all unplanned readmissions for patients who meet the
specified denominator criteria. Unplanned readmissions are captured from
acute clinical events requiring urgent re-hospitalization within 30 days
of discharge (from an index admission). This standardized time frame is
necessary so that patients may be uniformly compared, and the 30-day time
frame is chosen for its proven clinical significance in readmission rates
(see attached references). Note that a readmission is also
eligible as an index admission if it meets all other eligibility
criteria. If the first admission after discharge is planned, then no
readmission is considered in the outcome, regardless of whether a
subsequent unplanned readmission takes place because it would be unfair
to attribute the unplanned readmission back to the care received during
the index admission (consistent with NQF-endorsed measure #1789; 30-Day
Hospital-Wide All-Cause Unplanned Readmission, which excludes patients
admitted to a PPS-Exempt Cancer Center and patients receiving medical
treatment for cancer).
Measure Specifications
- NQF Number (if applicable): 0225
- Description: Percentage of patients >18yrs of age, who
have primary colon tumors (epithelial malignancies only),
experiencing their first diagnosis, at AJCC stage I, II or III who
have at least 12 regional lymph nodes removed and pathologically
examined for resected colon cancer. 1b.1. Developer Rationale:
Improved survival for patients
- Numerator statement: Greater than or equal to 12 regional
lymph nodes pathologically examined.
- Denominator statement: Regional Lymph Nodes Positive[For
reference, denominator of endorsed measure in QPS: Include, if all of
the following characteristics are identified:Age >=18 at time of
diagnosisKnown or assumed to be first or only cancer diagnosisPrimary
tumors of the colonEpithelial malignancy onlyAJCC Stage I, II, or
IIISurgical resection performed at the reporting facility]
- Exclusions: Exclude, if any of the following
characteristics are identified: Age <18; not a first or only
cancer diagnosis; non-epithelial and non-invasive tumors; metastatic
disease (AJCC Stage IV); not treated surgically at the reporting
facility
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Paper Medical Record, Registry
- Measure type: Process
- Steward: American College of Surgeons
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to conditionally
support this measure pending inclusion of this measure in the IQR
program for general acute care hospitals. The Workgroup noted that
this measure has extremely high levels of performance for the PPS
Exempt Cancer Hospitals; however, it is important to set the
benchmark for the broad range of hospitals providing cancer care.
Alignment on this measure across settings is an important goal. The
MAP also noted that this measure has been tested for the appropriate
level of analysis, is NQF endorsed, and supports alignment across
programs. This measure is used by the American College of
Surgeons’ Commission on Cancer. This measure has been in use by the
Commission on Cancer since 2007. While this measure is not currently
included in another federal program, it is part of the MAP Cancer
Family of Measures. This measure would help to address a gap in colon
cancer care previously identified by the Hospital
Workgroup.
- Public comments received: 4
Rationale for measure provided by HHS
CoC-accredited
(Commission on Cancer) facilities are eligible to submit data for this
measure. This is a Quality Improvement measure and has already been
endorsed by the CoC. Improved survival for patients with a greater number
of lymph nodes resected ;greater accuracy of staging for patients, and
consequently appropriate post-surgical care Chang GJ, Rodriguez-Bigas
MA Skibber JM et al. Lymph node evaluation and survival after curative
resection of colon cancer: systematic review. JNCI 2007; 99(6)L433-441.
2. Le Voyer TE, Sigurdson ER, Hamlin AL et al. Colon cancer survival is
associated with increasing number of lymph nodes analyzed: a secondary
survey of intergroup trial INT-0089. J Clin Oncol 2003; 21:2912-2919. 3.
Sarli L, Bader G, Lusco D, et al. Number of lymph nodes examined
and prognosis of TNM stage II colorectal cancer. European Journal of
Cancer 2005; 41:272-279. 4. Swanson RS, Compton CC, Stewart AK, Bland KI.
The prognosis of T3N0 clon cancer is dependent on the number of lymph
nodes examined. Ann Surg Oncol 2003; 10(1):65-71
Measure Specifications
- NQF Number (if applicable): 1641
- Description: Percentage of patients with chart
documentation of preferences for life sustaining treatments.
- Numerator statement: Patients whose medical record
includes documentation of life sustaining preferences
- Denominator statement: Seriously ill patients enrolled in
hospice OR receiving specialty palliative care in an acute hospital
setting.
- Exclusions: Patients with length of stay < 1 day in
palliative care or < 7 days in hospice
- HHS NQS Priority: Patient and Family Engagement
- HHS Data Source: EHR, Other (please list in GTL comment
field)
- Measure type: Process
- Steward: University of North Carolina- Chapel Hill
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: While overall MAP was very supportive
of the idea of this measure, the group noted some concerns. MAP
conditionally supported this measure pending clarifications and
updates to the measure specifications with a review and endorsement
by the relevant NQF Standing Committee of these updates.
Specifically, members of the group want to see clarification of the
definition of seriously ill, and a broadening of the denominator to
include patients followed by a palliative care or supportive care
team, not just those in a palliative care unit. MAP generally agreed
that this measure addresses the critical program objectives of
PPS-Exempt Cancer HQPR, has been tested for the appropriate level of
analysis, is NQF endorsed, and supports alignment across programs.
This measure would begin to fill previously identified gaps in
treatment preferences and palliative care. It is part of the MAP
Hospice and Palliative Care Family of Measures.
- Public comments received: 7
Rationale for measure provided by HHS
The National
Priorities Partnership has identified palliative and end-of-life care as
one of its national priorities. A goal of this priority is to ensure that
all patients with life-limiting illness have the right to express
preferences that guide use of invasive or life-sustaining forms of
treatment.(1) The affected populations are large; in 2009, 1.56 million
people with life-limiting illness received hospice care.(2) In 2008,
58.5% of US hospitals with 50 or more beds had some form of palliative
care service, and national trends show steady expansion of these
services.(3) Patients and family caregivers rate control over treatment
decisions as a high priority when living with serious and life-limiting
illnesses. (4) From a recent systematic review of clinical trials,
moderate evidence supports "care planning through engaging values,
involving skilled facilitators, and focusing on key decision makers.”
These studies found improved outcomes of patient-physician
communication, improved satisfaction with care, and increased hospice
enrollment.(5) The more recently published Coping with Cancer Study, a
prospective observational study of over 300 patients with advanced
cancer, found that communication of patient treatment preferences was
associated with use of treatments honoring those preferences and wish
lesser use of aggressive, high-cost treatments.(6,7) This measure will
enhance patient autonomy, facilitate patient-centered decision-making,
and communicate patient preferences via documentation to other
treating providers.
1.http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=608
2. NHPCO Facts and figures: hospice care in America 2010 edition
http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf
3. Center to Advance Palliative Care
http://www.capc.org/news-and-events/releases/04-05-10 4.Singer PA, Martin
DK, Kelner M. Quality end-of-life care: patients´ perspective. JAMA 1999;
281: 163-168. 5. Lorenz KA, Lynn J, Dy SM et al. Evidence for improving
palliative care at the end of life: a systematic review. Ann Intern Med
2008: 148:147-159. 6. Wright AA, Mack JW, Kritek PA, Balboni TA, Massaro
AF, Matulonis UA, Block SD, Prigerson HG. Influence of patients’
preferences and treatment site on cancer patients’ end of life care.
Cancer. 2010 Oct 1;?116(19):4656-63. 7. Wright AA, Zhang B, Ray A et al.
Associations between end-of-life discussions, patient mental
health, medical care near death, and caregiver bereavement adjustment.
JAMA 2008; 300:1665-1673.
Measure Specifications
- NQF Number (if applicable): 1659
- Description: Inpatients age 6 months and older discharged
during October, November, December, January, February or March who
are screened for influenza vaccine status and vaccinated prior to
discharge if indicated.
- Numerator statement: Inpatient discharges who were
screened for influenza vaccine status and were vaccinated prior to
discharge if indicated.
- Denominator statement: Acute care hospitalized inpatients
age 6 months and older discharged during October, November, December,
January, February or March.
- Exclusions: Excluded patients consist of the following;
Patients who expire prior to hospital discharge and patients with an
organ transplant during the current hospitalization. See the 2a1.9
for ICD-9 and ICD-10 tables for transplants. Patients who have a
Length of Stay greater than 120 days. Patients who are transferred or
discharged to another acute care hospital. Patients who leave Against
Medical Advice (AMA).[For reference, additional exclusion
included for endorsed measure in QPS: Patients for whom vaccination
was indicated, but supply had not been received by the hospital due
to problems with vaccine production or distribution. ]
- HHS NQS Priority: Best Practice of Healthy Living
- HHS Data Source: Administrative Claims, Paper Medical
Record
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: This measure addresses the critical
program objectives of the PCHQR program, has been tested for the
appropriate level of analysis, is NQF endorsed, and supports
alignment across programs. This measure has been identified as a
disparities-sensitive measure and it is part of the MAP Dual Eligible
Beneficiaries Family of Measures and the Population Health Family of
Measures. Additionally, Hospital Compare shows a national average of
90% on this measure, indicating less than optimal performance and
potential for improvement. Several workgroup members encouraged
the measure developers to consider the exclusions for this measure,
specifically an exclusion for patients receiving anti-B-cell
antibodies (such as rituximab) and patients receiving intensive
chemotherapy such as that for induction or
consolidation.
- Public comments received: 3
Rationale for measure provided by HHS
Fill a measure gap in
program and alignment of measures. Up to 1 in 5 people in the United
States get influenza every season (CDC, Key Facts). Each year an average
of approximately 226,000 people in the US are hospitalized with
complications from influenza and between 3,000 and 49,000 die from the
disease and its complications (Thompson WW, JAMA). Combined with
pneumonia, influenza is the nation’s 8th leading cause of death (Minino,
2004 National Center for Health Statistics). Up to two-thirds of
all deaths attributable to pneumonia and influenza occur in the
population of patients that have been hospitalized during flu season
regardless of age (Fedson). The Advisory Committee on Immunization
Practices (ACIP) recommends seasonal influenza vaccination for all
persons 6 months of age and older to highlight the importance of
preventing influenza. Vaccination is associated with reductions in
influenza among all age groups (CDC Press Release February 24, 2010). The
influenza vaccination is the most effective method for preventing
influenza virus infection and its potentially severe complications.
Screening and vaccination of inpatients is recommended, but
hospitalization is an underutilized opportunity to provide vaccination to
persons 6 months of age or older.
Measure Specifications
- NQF Number (if applicable): 0431
- Description: Percentage of healthcare personnel (HCP) who
receive the influenza vaccination.
- Numerator statement: HCP in the denominator population who
during the time from October 1 (or when the vaccine became available)
through March 31 of the following year: (a) received an influenza
vaccination administered at the healthcare facility, or reported in
writing (paper or electronic) or provided documentation that
influenza vaccination was received elsewhere; or (b) were determined
to have a medical contraindication/condition of severe allergic
reaction to eggs or to other component(s) of the vaccine, or
history of Guillain-Barré Syndrome within 6 weeks after a previous
influenza vaccination; or (c) declined influenza vaccination; or (d)
persons with unknown vaccination status or who do not otherwise meet
any of the definitions of the above-mentioned numerator categories.
Numerators are to be calculated separately for each of the above
groups.
- Denominator statement: Number of HCP who are working in
the healthcare facility for at least 1 working day between October 1
and March 31 of the following year, regardless of clinical
responsibility or patient contact. Denominators are to be calculated
separately for: (a) Employees: all persons who receive a direct
paycheck from the reporting facility (i.e., on the facility’s
payroll). (b) Licensed independent practitioners: include physicians
(MD, DO), advanced practice nurses, and physician assistants only who
are affiliated with the reporting facility who do not receive a
direct paycheck from the reporting facility. (c) Adult
students/trainees and volunteers: include all adult students/trainees
and volunteers who do not receive a direct paycheck from the
reporting facility.
- Exclusions: None
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Process
- Steward: Centers for Disease Control and Prevention
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: This measure addresses the critical
program objectives of the PCHQR program, has been tested for the
appropriate level of analysis, is NQF endorsed, and supports
alignment across programs.This measure is being used in the
Ambulatory Surgical Center Quality Reporting Program, the Hospital
Inpatient Quality Reporting Program, the Inpatient Rehabilitation
Facilities Quality Reporting Program, and the Long-term Care Hospital
Quality Reporting Program. This measure is also included in Joint
Commission accreditation programs. Several members noted that this
measure does not include masking or other methods to prevent
transmission; however, overall the MAP agreed that the measure as
specified for inclusion in this program.
- Public comments received: 4
Rationale for measure provided by HHS
Fill gap in program
and for measure alignment across programs Use of this measure to monitor
influenza vaccination among HCP is envisioned to result in increased
influenza vaccination uptake among HCP, because improvements in tracking
and reporting HCP influenza vaccination status will allow healthcare
institutions to better identify and target unvaccinated HCP. Increased
influenza vaccination coverage among HCP is expected to result in reduced
morbidity and mortality related to influenza virus infection among
patients. 1. Hayward AC, Harling R, Wetten S, et al. Effectiveness of an
influenza vaccine programme for care home staff to prevent death,
morbidity, and health service use among residents: cluster randomized
controlled trial. BMJ 2006; 333: 1241-1246. 2. Potter J, Stott DJ,
Roberts MA, et al. Influenza vaccination of healthcare workers in
long-term-care hospitals reduces the mortality of elderly patients. J
Infect Dis. 1997; 175:1-6. 3. Lemaitre M, Meret T, Rothan-Tondeur M, et
al. Effect of influenza vaccination of nursing home staff on mortality of
residents: a cluster-randomized trial. J Am Geriatr Soc. 2009;
57:1580-1586. 4. Carman WF, Elder AG, Wallace LA, et al. Effects of
influenza vaccination of health-care workers on mortality of elderly
people in long-term care: a randomized controlled trial. Lancet 2000;
355:93–97. 5. Talbot TR, Babcock H, Caplan AL, et al. Revised SHEA
position paper: influenza vaccination of healthcare personnel. Infection
Control and Hospital Epidemiology 2010; 31:987-995.
Measure Specifications
- NQF Number (if applicable): 1717
- Description: Standardized infection ratio (SIR) of
hospital-onset CDI Laboratory-identified events (LabID events) among
all inpatients in the facility, excluding well-baby nurseries and
neonatal intensive care units (NICUs)
- Numerator statement: Total number of observed
hospital-onset CDI Lab ID events among all inpatients in the
facility, excluding well baby-nurseries and NICUs
- Denominator statement: Total number of expected
hospital-onset CDI LabID events, calculated using the facility´s
number of inpatient days, bedsize, affiliation with medical school,
microbiological test used to identify C. difficile, and
community-onset CDI admission prevalence
- Exclusions: Data from patients who are not assigned to an
inpatient bed are excluded from the denominator counts, including
outpatient clinic and emergency department visits. Additionally, data
from well-baby nurseries and NICUs are excluded from the denominator
count.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: This measure addresses the critical
program objectives of the PCHQR program, has been tested for the
appropriate level of analysis, is NQF endorsed, and supports
alignment across programs. This measure would promote alignment
between programs assessing general acute care and cancer hospitals
(IQR and PCHQR). This measure is also included in the MAP Safety
Family of Measures.
- Public comments received: 3
Rationale for measure provided by HHS
Addresses a gap in
the program Clinical guidelines for the management of C. difficile have
been published. Adherence to the recommendations in the guidelines can
result in decreased rates of C. difficile transmission and infection.
Decreasing rates of infection will result in a lower SIR, which indicates
improving performance. Cohen SH, Gerding DN, et al. Clinical Practice
Guidelines for Clostridium difficile Infection in Adults: 2010 Update
by the Society for Healthcare Epidemiology of America (SHEA) and the
Infectious Diseases Society of America (IDSA). Infect Control Hosp
Epidemiol, 2010. 31(5):431-455. Rutala WA, Weber DJ, and the Healthcare
Infection Control Practices Advisory Committee. Guideline for
Disinfection and Sterilization in Healthcare Facilities, 2008. Available
at http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee. 2007 Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings. Available at
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Boyce JM,
Pittet D, et al. Guideline for Hand Hygiene in Health-Care Settings:
Recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR,
2002. 51(RR-16).
Measure Specifications
- NQF Number (if applicable): 1716
- Description: Standardized infection ratio (SIR) of
hospital-onset unique blood source MRSA Laboratory-identified events
(LabID events) among all inpatients in the facility
- Numerator statement: Total number of observed
hospital-onset unique blood source MRSA LabID events among all
inpatients in the facility
- Denominator statement: Total number of expected
hospital-onset unique blood source MRSA LabID events, calculated
using the facility´s number of inpatient days, bedsize, affiliation
with medical school, and community-onset MRSA bloodstream infection
admission prevalence rate.
- Exclusions: Data from patients who are not assigned to an
inpatient bed are excluded from the denominator counts. These include
outpatient clinic and emergency department visits.
- HHS NQS Priority: Making Care Safer
- HHS Data Source: National Healthcare Safety Network
- Measure type: Outcome
- Steward: Centers for Disease Control and Prevention
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The measure was conditionally
supported, pending? stratification for cohorts of cancer patients
(BMT, Hematologic, and Solid tumor). This measure addresses the
critical program objectives of PPS-Exempt Cancer HQPR, has been
tested for the appropriate level of analysis, is NQF endorsed, and
supports alignment across programs. This measure would promote
alignment between programs assessing general acute care and cancer
hospitals (IQR and PCHQR). This measure is included in the MAP Safety
Family of Measures.
- Public comments received: 2
Rationale for measure provided by HHS
Cover gap in program
and for measure alignment The SIR compares a healthcare facility´s
performance compared to a national baseline. Facilities are able to see
whether the number of LabID events that they have reported compares to
the number that would be expected, given national data. The measure can
then be used to drive prevention practices that will lead to improved
outcomes, including the reduction of patient morbidity and mortality.
Siegel, JD, et al., Guideline for Management of Multidrug-Resistant
Organisms In Healthcare Settings, 2006. Available at
http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf.
Measure Specifications
- NQF Number (if applicable): 0221
- Description: Percentage of patients presenting with AJCC
Stage Group 0, I, II, or III disease, who undergo surgical
excision/resection of a primary breast tumor who undergo a needle
biopsy to establish diagnosis of cancer preceding surgical
excision/resection.
- Numerator statement: Patient whose date of needle biopsy
precedes the date of surgery.
- Denominator statement: Women with AJCC Stage 0, I, II, or
II breast cancer undergoing surgery: • Women • Age 18 at time of
diagnosis • Known or assumed first or only cancer diagnosis • Primary
tumors of the breast • Epithelial invasive malignancy only •
Surgically treated • Diagnosis and all or part of first course of
treatment performed at the reporting facility
- Exclusions: Exclusions: Men; not a first or only cancer
diagnosis; non-epithelial tumors; metastatic disease (AJCC Stage IV);
not treated surgically; died before surgery
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Registry
- Measure type: Process
- Steward: American College of Surgeons
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The MAP agreed to conditionally
support this measure pending inclusion of this measure in the IQR
program for general acute care hospitals. The Workgroup noted that
this measure has extremely high levels of performance for the PPS
Exempt Cancer Hospitals; however, it is important to set the
benchmark for the broad range of hospitals providing cancer care.
Alignment on this measure across settings is an important goal. The
MAP also noted that this measure has been tested for the appropriate
level of analysis, is NQF endorsed, and supports alignment across
programs. This measure is used by the American College of
Surgeons’ Commission on Cancer. This measure has been in use by the
Commission on Cancer since 2007. While this measure is not currently
included in another federal program, it is part of the MAP Cancer
Family of Measures. This measure would fill a gap in cancer care
previously identified by the Hospital workgroup. Workgroup members
and commenters also requested clarification on the exclusions for
this measure which the developer stated were addressed during the NQF
Annual Update. The developer will submit comments to clarify these
updates in the upcoming comment period.
- Public comments received: 3
Rationale for measure provided by HHS
Improve the
utilization of needle biopsy prior to surgery for breast cancer with
resultant decreased morbidity and increased cost effectiveness, and
patient satisfaction Williams RT, Yao KT, Stewart AK et al. Needle versus
excisional biopsy for noninvasive and invasive breast cancer, report from
the National Cancer Data Base 2003-2008. Ann Surg Oncol
2011;18(13):3802-10. 2. Friese CR, Neville BA, Edge SB et al. Breast
biopsy patterns and outcomes in Surveillance, Epidemiology, and End
Results-Medicare data. Cancer 2009;115(4):716-24. 3. Holloway CM, Saskin
R, Paszat L. Geographic variation and physician specialization in the use
of percutaneous biopsy for breast cancer diagnosis. Can J Surg
2008;51(6):453-63. 4. Clarke-Pearson EM, Jacobson AF, Boolbol SK et al.
Quality assurance initiative at one institution for minimally invasive
breast biopsy as the initial diagnostic technique. J Am Coll Surg
2009;208(1):75-8.
Measure Specifications
- NQF Number (if applicable): 0219
- Description: Percentage of female patients, age 18-69, who
have their first diagnosis of breast cancer (epithelial malignancy),
at AJCC stage I, II, or III, receiving breast conserving surgery who
receive radiation therapy within 1 year (365 days) of
diagnosis.
- Numerator statement: Radiation therapy to the breast is
initiated within 1 year (365 days) of the date of diagnosis
- Denominator statement: Include, if all of the following
characteristics are identified: Women Age 18-69 at time of diagnosis
Known or assumed to be first or only cancer diagnosis Primary tumors
of the breast Epithelial malignancy only AJCC Stage I, II, or III
Surgical treatment by breast conservation surgery (surgical excision
less than mastectomy) All or part of 1st course of treatment
performed at the reportingfacility.[For reference, additional text
included on denominator in endorsed measure’s description in QPS:
Known to be alive within 1 year (365 days) of diagnosis]
- Exclusions: Exclude, if any of the following
characteristics are identified: Men Under age 18 at time of
diagnosis; Over age 69 at time of diagnosis; Second or subsequent
cancer diagnosis; Tumor not originating in the breast; Non-epithelial
malignancies; Stage 0, in-situ tumor; Stage IV, metastatic tumor;
None of 1st course therapy performed at reporting facility; Died
within 12 months (365 days) of diagnosis
- HHS NQS Priority: Effective Prevention and Treatment
- HHS Data Source: Paper Medical Record, Registry
- Measure type: Process
- Steward: American College of Surgeons
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP agreed to conditionally support
this measure pending inclusion of this measure in the IQR program for
general acute care hospitals. The Workgroup noted that this measure
has extremely high levels of performance for the PPS Exempt Cancer
Hospitals; however, it is important to set the benchmark for the
broad range of hospitals providing cancer care. Alignment on this
measure across settings is an important goal. The MAP also noted that
this measure has been tested for the appropriate level of
analysis, is NQF endorsed, and supports alignment across programs.
This measure is used by the American College of Surgeons’ Commission
on Cancer. This measure has been in use by the Commission on Cancer
since 2007. While this measure is not currently included in another
federal program, it is part of the MAP Cancer Family of Measures.
This measure would fill a gap in breast cancer care previously
identified by the Hospital workgroup.
- Public comments received: 3
Rationale for measure provided by HHS
CoC-accredited
(Commission on Cancer) facilities have the ability to submit this data.
Measure is already NQF-endorsed. There is an extensive literature
demonstrating variations in the use of radiation with breast conservation
surgery based on factors including age, race/ethnicity, socioeconomic
status, location of treatment, provider, tumor characteristics, and
other factors. Daroui P, Gabel M, Khan AJ, Haffty BG, Goyal S.
Utilization of breast conserving therapy in Stage 0, I, and II breast
cancer patients in New Jersey: An American College of Surgeons National
Cancer Data Base (NCDB) Analysis. Am J Clin Oncol 2011; Feb 15(epub ahead
of print). 2. Smith Gl, Shih YC, Xu Y, et al. Racial disparities in the
use of radiotherpay after breast conserving surgery: a national Medicare
study. Cancer 2010;11:734-741. 3. Bickell NA, Wang JJ, Oluwole S, et al.
Missed opportunities: racial disparities in adjuvant breast cancer
treatment. J Clin Oncol 2006;24:1357-1362.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP agrees that cluster headaches are
underdiagnosed and undertreated. Conditional on submission to NQF for
endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development of
this high-value, patient reported outcome measure.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development of
this process measure that addresses patient-centered care, end of
life care and is a priority for dual eligibles. MAP suggests
including palliative care referrals and advanced care
planning.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: No longer under consideration by
CMS
- Workgroup Rationale: No longer under consideration per
CMS.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that the literature
supports the role of alcohol in trauma - this measure will stimulate
a practice change. This is a screening measure with follow-up.
Follow-up needs further definition: Who/what is acceptable follow-up?
What is included? How is the fact that follow-up occurred captured in
the measure?
- Public comments received: 2
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
| Amblyopia
Screening in Children (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3817)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: 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). MAP indicates the measure needs to take in to account how
children are screened, the tool that is used and who is doing the
screening.
- Public comments received: 3
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 (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3811)
|
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Intermediate Outcome
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP supports this 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.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Public comments from steward
acknowledges similarity with X3769 and a need for harmonization and
alignment. MAP supports development of a single, fully harmonized
measure for overuse of colonoscopy.
- Public comments received: 3
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
high-value, appropriate use of imaging measure. MAP applauds a
measure that encourages radiologists' role in care
coordination.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
high-value, appropriate use of imaging measure. MAP applauds a
measure that encourages radiologists' role in care
coordination.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP suggests that although this
measure encourages use of low-cost test before ordering an MRI, high
performers may still overuse MRIs. American College of Radiology
notes a lack of hard stop appropriateness criteria. MAP asked - What
is the pathway to true appropriateness measures?
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP suggests that although this
measure encourages use of low-cost test before ordering an MRI, high
performers may still overuse MRIs. American College of Radiology
notes a lack of hard stop appropriateness criteria.
- Public comments received: 1
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 (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3274)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this measure in a new
condition area. Conditional on satisfactory testing at the clinician
level and submission to NQF for consideration for
endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this patient safety
measure for assessing potential overuse of medications. Conditional
on testing at the clinician-level and submission to NQF.
- Public comments received: 2
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 (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: E1553)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: MAP notes that 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.
- Public comments received: 0
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 (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3797) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this NQF-endorsed
population measure important to consumers; it is consistent with the
most recent guidelines and important for dual eligibles. NQF endorsed
this measure at the plan and system level -- conditional on
successful testing for reliability and validity at the clinician
level. The developer should also consider including patient
willingness to be screened in the measure.
- Public comments received: 2
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).
| Cervical Cancer
Screening (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: E0032) |
Measure Specifications
- 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: Best Practice of Healthy Living
- HHS Data Source: Claims, Paper Medical Record
- Measure type: Process
- Steward: National Committee for Quality Assurance
- Endorsement Status: Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this NQF-endorsed
population measure important to consumers; it is consistent with the
most recent guidelines and important for dual eligibles. The drawback
to this measure is that it does not discourage overuse; CMS is
developing an overuse measure. MAP agrees this measures should be
paired with an overuse measure. NQF endorsed this measure at the plan
and system level -- conditional on successful testing for reliability
and validity at the clinician level.
- Public comments received: 0
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Measures X3774, X3777, X3776, X3775
address the important area chronic opioid use which is a new topic
area for PQRS measures. MAP indicates that more specificity is needed
for what is expected at the follow-up evaluation.
- Public comments received: 5
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP acknowledged this rapidly
changing and evolving practice and supports development of this
outcome measure. Large programs are performing 1-2 cases/week. The
measure may need clinical selection criteria or risk adjustment. MAP
strongly recommends a similar outcome measure for all stroke
patients.
- Public comments received: 6
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this outcome measure in
a new condition area. Conditional on satisfactory testing at the
clinician level and submission to NQF for consideration for
endorsement.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this suite of related measures related to care coordination
including X3283, X3465, X3466. MAP believes these measures are
necessary but not sufficient to measure quality for care
coordination. The developers indicate that these are "building block"
measures. MAP notes that measure’s title should be revised to
reflected that a referral was initiated and not closed. Good EHR
systems are needed and measures should assess whether systems are
being used effectively. Streamlining the transmission of notes that
PCP’s receive through EHR’s is necessary -- there are multiple
pathways within an EHR to get a response from a specialist. The
measure applies to all EPs.
- Public comments received: 8
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this high-value measure of appropriate use for lab tests in the
ED.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: The Medicare Annual Wellness Visit
specifies "detection of any cognitive impairment". No evidence for
general screening for cognitive impairment. Providers should have
heightened awareness and finely tuned antennae for case finding for
dementia. Important for dual eligibles. Important topic but
significant concerns with the measure. MAP would like to revisit when
measure is more fully developed.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP concludes that this is a
documentation measure that should be fulfilled by informed consent.
MAP encourages further development of a measure that includes the
goals of care, patient agreement with the goals and plan and advanced
care planning. A substantial re-design to a patient-reported measure
would be best.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this additional process
measure for GYN and GU specialists conditional on submission to NQF.
MAP recommends a composite measure of all required preoperative
evaluations in MUCs X3751, X3746, X3741, X3742.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of workgroup deliberations: Consensus not reached.
Measures X3774, X3777, X3776, X3775 address the important area chronic
opioid use which is a new topic area for PQRS measures. MAP members note
that although measuring an important concept, this is little more than a
simple documentation measure. The Clinician Workgroup did not reach
consensus because some believed the topic is important even though this
is a low value measure.
Public comments received: 3
Preliminary Analysis of Measure
- 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. No testing data found.
- 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)
| Controlling High
Blood Pressure (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3792) |
Measure Specifications
- 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
Summary of workgroup deliberations: Consensus not reached. MAP
discussed the ongoing controversy and changing guidelines around BP
traget values. MAP did not reach consensus noting concerns about
guidelines not being finalized and changing measure specifications too
frequently. MAP would want the measure to be reviewed by NQF pending
final hypertension guidelines from AHA/ACC due in 2015
Public comments received: 3
Preliminary Analysis of Measure
- 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. Measure addresses an
intermediate-outcome.-Measure targets an all-payer 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. Measure is in use in
the HEDIS and CMS EHR Incentive Program
- 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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This measure with MUC # X3283 and
X3465 are building blocks toward a more effective system. MAP
suggests it would be better to separate asthma from chest pain - the
measure is more appropriate for asthma and 7 day follow-up is more
appropriate than 3 days for the clinical course. Chest pain should
specify "atraumatic chest pain". MAP suggests this measure should
include "or designee" as in X 3465.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Suite of related measures include
X3283, X3465, X3466. MAP agrees that including "or designee" is
appropriate - similar language should be used in X 3466.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this 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. This
measure is also important for dual eligibles. Conditional on NQF
review and further consideration of evidence for age specifications.
Suggest amending denominator to "on a antihyperglycemic
medication other than metformin…" Metformin does not have
hypoglycemic side effects.
- Public comments received: 7
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
for this care coordination for a condition important in Medicare and
for dual eligibles. The measure should include advanced directives
and patient goals. Proxy must be informed and aware of patient
wishes.
- Public comments received: 7
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Measures X3774, X3777, X3776, X3775
address the important area chronic opioid use which is a new topic
area for PQRS measures. MAP agrees there is limited evidence on
effectiveness but a signed agreement is recommended by multiple
societies. Conditional on submission to NQF for endorsement. A
composite would be appropriate for this group of
measures.
- Public comments received: 6
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
measure. 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.
- Public comments received: 6
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Measures X3774, X3777, X3776, X3775
address the important area chronic opioid use which is a new topic
area for PQRS measures. MAP supports development of a composite
measure. There are no exclusions --MAP has concerns about the impact
on palliative care patients. The measures address the tension between
pain management and preventing abuse though better measures are
needed.
- Public comments received: 5
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)
Measure Specifications
- 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 (please list in
GTL comment field)
- Measure type: Outcome
- Steward: American College of Radiology
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
high-value adverse outcome and patient safety measure. MAP notes that
this is a quality problem that could affect all ages.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development of
the measure because patients captured in this measure represent
wasted resources.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that this measure has an
overly large denominator and should consider principal diagnosis or
pain/function threshold to be captured in the denominator. MAP
prefers development as a patient-reported functional 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. A true functional status
measure would be related to the functional status measures for hip
and knee replacement (X3482 and X3483).
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP is delighted to see development
of true patient-reported, functional outcome measures like this. MAP
hopes the eMeasure will be ready for use very soon and notes that the
same tool should be used to assess before and after surgery.
Conditional on submission to NQF for endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP is delighted to see development
of true patient-reported, functional outcome measures like this. MAP
hopes the eMeasure will be ready for use very soon and notes that the
same tool should be used to assess before and after
surgery.
- Public comments received: 4
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.
| Gout: Serum Urate
Monitoring (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: S2521) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not encourage further
consideration
- Workgroup Rationale: NQF did not approve this eMeasure for
Trial Use due to lack of evidence of relationship to patient
outcomes. Monitoring of blood level is not related to response to
therapy.
- Public comments received: 1
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 (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: S2550)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: 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.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
process eMeasure of appropriate treatment after a positive HCV
screening test. MAP suggests combining or pairing with
X3512.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this population health screening eMeasure aligned with CDC
recommendations.
- Public comments received: 5
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
| HIV Screening of
STI patients (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3300) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This eMeasure 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.
- Public comments received: 2
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: Ever
screened for HIV (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3299)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: 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.
- Public comments received: 1
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP clarified that specification that
the Glasgow Coma Score equals 15.MAP encourages continued development
of this ?high-value measure of appropriate use of imaging in the ED.
Inappropriate use of imaging results in increased healthcare
expenditures, unnecessary patient radiation exposure, and possibly
prolonged evaluation times.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP clarified that specification that
the Glasgow Coma Score equals 15.MAP encourages continued development
of this ?high-value measure of appropriate use of imaging in the ED.
Inappropriate use of imaging results in increased healthcare
expenditures, unnecessary patient radiation exposure, and possibly
prolonged evaluation times.
- Public comments received: 4
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supports this high-value outcome
measure that is fully developed and NQF-endorsed. MAP notes some
concerns with sample size at the surgeon level. MAP clarified
specifications as "greater than or equal to 6 cm" and "greater than
or equal to 5.5 cm".
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
eMeasure version of an NQF-endorsed measure that captures all
patients on warfarin regardless of diagnosis. This is a patient
safety measure.
- Public comments received: 2
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP suggested that it is unclear how
to ascertain that effective screening occurred and the measure should
include follow-up. MAP supports integrating behavioral health into
primary care - teams may have a variety of appropriate
providers.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: The 5 prior MUCs for muscular
dystrophy are more specific aspects of the care plan. This process
measure may add little. Plan of care should include discussion with
the patient and patient agreement with the plan. Conditional on
testing at the clinician-level, evaluating usefulness to potential
audiences and submission to NQF.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this measure of
appropriate treatment for acute migraines attacks. Conditional on
submission to NQF for endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP notes 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 similar to MUC X3786 for
Quality of Life. Conditional on testing at the clinician-level and
submission to NQF.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Maintaining adequate nutrition and
body weight is important for optimizing strength, function, and
quality of life in patients with muscular dystrophy. Conditional on
testing at the clinician level and submission to NQF.
- Public comments received: 3
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 (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3773) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: 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. Relative improvement for severe asthmatics is not
included. Minnesota uses comparisons of like providers, i.e.,
pulmonologist compared to each other, etc. Upper age limit of 50
years may not be warranted as increasing number of older patient have
asthma.
- Public comments received: 4
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 (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: E0076) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP conditionally supports this
revised composite measures for vascular care that has removed the
lipid component due to recent changes in the guidelines. Conditional
on successful maintenance review of revised measure by
NQF.
- Public comments received: 4
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this 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.
- Public comments received: 3
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%).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this appropriate use
measure. Conditional on testing at the clinician level and submission
to NQF for endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: This measure is duplicative of
measure under consideration X3774 for patients taking opioid
regardless of diagnosis.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this measure of 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.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this process measure
addresses systematic assessment for pain. Conditional on successful
testing at the clinician level and submission to NQF. MAP would like
to see this measure evolve to a patient-reported
outcome.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: Muscular dystrophy is a group of nine
inherited diseases of progressive muscle 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 clinician-level
and submission to NQF.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: Duplicative of measure under
consideration X3768 that is already in use in private
programs.
- Public comments received: 1
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this pediatric care coordination measure that is important for
dual eligibles. Some public comments voiced concern about conflict
with conditions of coverage.
- Public comments received: 3
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)
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This is a process measure of patients
receiving a survey before and after the procedure. MAP prefers a
patient-reported outcome measure that compares the survey results
before and after surgery.
- Public comments received: 3
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this measure of follow-up after procedure performed by
interventional radiologists. This is an overlooked area. Many
patients are lost to follow-up. Most filters never removed and can
cause later complications. The measure promotes care coordination.
MAP also noted that filters are overused.
- Public comments received: 2
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
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP recommends a composite measure
with MUC X3743, X3813, X3744 (adverse outcomes) and MUC X3752, X3740
(process measures) for parsimony. Conditional on submission to
NQF.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: MAP supports this NQF-endorsed
patient safety process measure to identify and correct potential
complications during surgery. MAP recommends creating a composite
measure with MUC X3743, X3813, X3744 (adverse outcomes) and MUC
X3752, X3740 (process measures to assess for potential adverse
outcomes) for parsimony.
- Public comments received: 2
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).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: For MSSP MAP supports including this
NQF-endorsed, evidence-based process measure in a composite measure.
This measure promotes secondary prevention of vascular disease beyond
the timeframe of surgery. Complements two outcome measures for this
procedure.
- Public comments received: 2
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).
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process [Change made from publically posted
MUC list after discussion with CMS]
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this intermediate outcome measure revised from a prior process
measure. It is an additional measure for anesthesia. MAP recommends
clarification of the specifications as discussed with the NQF Surgery
Standing Committee in May 2014 as the measure is further developed
and tested.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages further development of
this measure that captures the completeness of the colonoscopy
procedures used for screening and surveillance for colorectal cancer.
MAP suggests a composite measure to combine multiple measures of
colonoscopy performance.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP concludes that this plan of care
measure does not add much to measure X3771 and X3772 that addresses
acute and preventive treatment.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP notes that this process measure
follows up on the screening for medication overuse in MUC X3783. A
plan of care should include patient agreeing to plan. MAP would like
to see evolution to a PRO. Conditional on testing at the
clinician-level and submission to NQF.
- Public comments received: 2
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this 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 validity and meaningful differences among anesthesia
providers will be important.
- Public comments received: 2
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this 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 validity and meaningful differences among anesthesia
providers will be important.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP recommends this additional
process measure for GYN and GU specialists conditional on submission
to NQF. MAP recommends a composite measure of all required
preoperative evaluations in MUCs X3751, X3746, X3741,
X3742.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this additional process
measure for GYN and GU specialists. Conditional on submission to NQF.
MAP recommends a composite measure of all required preoperative
evaluations in MUCs X3751, X3746, X3741, X3742.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this additional process
measure for GYN and GU specialists conditional on submission to NQF.
MAP recommends a composite measure of all required preoperative
evaluations in MUCs X3751, X3746, X3741, X3742.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this additional process
measure conditional on submission to NQF. It is unclear the benefit
of two pessary measures (also X3750 pessary offered) and should be
combined.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this additional process
measure to consider an alternative to surgery conditional on
submission to NQF. Two pessary measures (also X3745 pessary
attempted) are not needed and should be combined.
- Public comments received: 1
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages continued development
of this evidence-based, preoperative process of care measure. It is
an additional measure for anesthesia.
- Public comments received: 2
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.
Measure Specifications
- 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
(please list in GTL comment field)
- Measure type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development o this
process measure includes evaluation of risk for PONV and
administration of appropriate preventive medications. However, MAP
would prefer an outcome measure of how many patient have
PONV.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP indicated that alcohol screening
and brief intervention is evidence based and encouraged further
development of this eMeasure.
- Public comments received: 9
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this measure of
appropriate preventive treatment for patients with frequent
migraines. Conditional on testing at the clinician-level and
submission for NQF endorsement.
- Public comments received: 4
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 (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3768) |
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this outcome measure
important to consumers. The measure is in use in Minnesota and will
be publicly reported very soon. The measure fills a gap in perinatal
measures. This clinician-level measure should be completely
harmonized with NQF-endorsed facility-level measure including
exclusions. Conditional testing at the clinician level and submission
to NQF.
- Public comments received: 1
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).
Measure Specifications
- 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 (please list in GTL comment field)
- Measure type: Outcome
- Steward: American Urogynecologic Society
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this high-value adverse
outcome measure for GU and GYN surgeons performing pelvic organ
prolapse surgeries conditional on submission to NQF. MAP recommends a
composite measure with MUC X3743, X3813, X3744 (adverse outcomes) and
MUC X3752, X3740 (process measures) for parsimony.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP recommends a composite measure
with MUC X3743, X3813, X3744 (adverse outcomes) and MUC X3752, X3740
(process measures) for parsimony. Conditional on submission to
NQF.
- Public comments received: 2
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP recommends a composite measure
with MUC X3743, X3813, X3744 (adverse outcomes) and MUC X3752, X3740
(process measures) for parsimony. Conditional on submission to
NQF.
- Public comments received: 1
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP is pleased to see this patient
reported outcome measure for quality of life in patients with
headaches. Conditional on testing at the clinician-level and
submission to NQF for endorsement.
- Public comments received: 3
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
high-value adverse outcome measure for interventional
radiologists.
- Public comments received: 2
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
| Scoliosis
Evaluation Ordered (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3798)
|
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: 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.
- Public comments received: 2
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.
Measure Specifications
- 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: EHR, Paper Medical Record, Registry
- Measure type: Process
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP notes that the measure conforms
to new guidelines for statin use and should replace prior measures
based on old guidelines. The measure does not address intensity of
statins. The specifications for LDL > 190 does not include age
specifications included in the guidelines.
- Public comments received: 5
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Several Workgroup members had
significant concerns that the two components relating to drug use are
not evidence based. A majority of the Workgroup, however, encouraged
further development of the measure noting that prescription and
illicit drug abuse is a large and growing problem.Public comments
also indicated concerns that complying with non-evidence-based
processes will take resources away from alcohol screening. The
Clinician Workgroup voted 67% to encourage further development; 33%
voted against.
- Public comments received: 14
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.
Measure Specifications
- 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 (please list in GTL
comment field)
- Measure type: Efficiency
- Steward: American Gastroenterological Association
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: Public comments from steward
acknowledges similarity with X3758 and a need for harmonization and
alignment. MAP supports development of a single, fully harmonized
measure for overuse of colonoscopy.
- Public comments received: 3
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;
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: This is a patient safety and
appropriate use measure for children and adolescents. It is also
important to dual eligibles.
- Public comments received: 0
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.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Encourage continued
development
- Workgroup Rationale: MAP encourages development of this
patient safety process measure to reduce risk of allergic reaction to
imaging contrast material. Developer indicates there is a gap in care
though MAP believes performance is likely to be high.
- Public comments received: 2
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.
Measure Specifications
- NQF Number (if applicable): 2510
- Description: This measure estimates the risk-standardized
rate of all-cause, unplanned, hospital readmissions for patients who
have been admitted to a Skilled Nursing Facility (SNF) (Medicare
fee-for-service [FFS] beneficiaries) within 30 days of discharge from
their prior proximal hospitalization. The prior proximal
hospitalization is defined as an admission to an IPPS, CAH, or a
psychiatric hospital. The measure is based on data for 12 months of
SNF admissions. A risk-adjusted readmission rate for each facility
is calculated as follows: Step 1: Calculate the standardized
risk ratio of the predicted number of readmissions at the facility
divided by the expected number of readmissions for the same patients
if treated at the average facility. The magnitude of the
risk-standardized ratio is the indicator of a facility’s effects on
readmission rates. Step 2: The standardized risk ratio is then
multiplied by the mean rate of readmission in the population (i.e.,
all Medicare FFS patients included in the measure) to generate the
facility-level standardized readmission rate. For this measure,
readmissions that are usually for planned procedures are excluded.
Please refer to the Appendix, Tables 1 - 5 for a list of planned
procedures. The measure specifications are designed to harmonize
with CMS’s hospital-wide readmission (HWR) measure to the greatest
extent possible. The HWR (NQF #1789) estimates the hospital-level,
risk-standardize rate of unplanned, all-cause readmissions within 30
days of a hospital discharge and uses the same 30-day risk window as
the SNFRM.
- Numerator statement: The numerator is defined as the
risk-adjusted estimate of the number of unplanned readmissions that
occurred within 30 days from discharge from the prior proximal acute
hospitalization.
- Denominator statement: The denominator includes all
patients who have been admitted to a SNF within one day of discharge
from a prior proximal hospitalization, taking denominator exclusions
into account.
- Exclusions: Numerator exclusions: We exclude for planned
readmissions as per the HWR measure. Denominator exclusions: The
following are excluded from the denominator: 1. SNF stays where the
patient had one or more intervening post-acute care (PAC) admissions
(inpatient rehabilitation facility [IRF] or long-term care hospital
[LTCH]) which occurred either between the prior proximal hospital
discharge and SNF admission or after the SNF discharge, within the
30-day risk window. Also excluded are SNF admissions where the
patient had multiple SNF admissions after the prior proximal
hospitalization, within the 30-day risk window. 2. SNF stays with a
gap of greater than 1 day between discharge from the prior proximal
hospitalization and the SNF admission. 3. SNF stays where the patient
did not have at least 12 months of FFS Medicare enrollment prior to
the proximal hospital discharge (measured as enrollment during the
month of proximal hospital discharge and for the 11 months prior to
that discharge). 4. SNF stays in which the patient did not have FFS
Medicare enrollment for the entire risk period (measured as
enrollment during the month of proximal hospital discharge and the
month following the month of discharge). 5. SNF stays in which the
principal diagnosis for the prior proximal hospitalization was
for the medical treatment of cancer. Patients with cancer whose
principal diagnosis from the prior proximal hospitalization was for
other diagnoses or for surgical treatment of their cancer remain in
the measure. 6. SNF stays where the patient was discharged from the
SNF against medical advice. 7. SNF stays in which the principal
primary diagnosis for the prior proximal hospitalization was for
“rehabilitation care; fitting of prostheses and for the adjustment of
devices”.
- HHS NQS Priority: Communication and Care Coordination
- HHS Data Source: Administrative Claims
- Measure type: Outcome
- Steward: Centers for Medicare & Medicaid Services
- Endorsement Status: Not Endorsed
Summary of Workgroup Deliberations
- Workgroup Recommendation: Support
- Workgroup Rationale: This measure addresses a PAC/LTC Core
Concept and is a required measure for the SNF value-based purchasing
program under the Protecting Access to Medicare Act of 2014 (PAMA).
MAP noted that this measure is well aligned with readmission measures
used in other settings. MAP did raise some concerns about potential
unintended consequences and recommended CMS look to other programs to
assess there are not increases in mortality or issues with patients
having access to hospitalization when needed. Some MAP members also
raised concerns that this measure excludes patients with
cancer and suggested CMS consider ways to include these patients in
future versions of the measure.
- Public comments received: 8
Rationale for measure provided by HHS
The Skilled Nursing
Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP
measure.
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Do not support
- Workgroup Rationale: MAP agreed that cellulitis is
heterogeneous and difficult to define. One half of costs are
inpatient including physician services, 25% is post-hospitalization
SNF costs. The measure doesn't capture the major variation in costs
which are in the hospital. Quality measures are needed in the topic
area.
- Public comments received: 4
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)).
Measure Specifications
- 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
Summary of workgroup deliberations: Consensus not reached. MAP
did not reach consensus on this episode based payment measure.
Gastrointestinal hemorrhage is heterogeneous and no quality measures
match up with this resource use measure. MAP is concerned that the
measure could disincentivize appropriate use of post-acute care. The
measure doesn't reflect the variation in inpatient costs. Developers
report 30% attributable to post-hospital care with variation in SNF and
physician services.
Public comments received: 3
Preliminary Analysis of Measure
- 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? .
- 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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a hip replacement surgery is very clearly
defined. Though surgery measures are finalized in PQRS, additional
quality measures specific to hip replacement are needed to match this
cost measure.
- Public comments received: 3
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)).
Measure Specifications
- 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
Summary of workgroup deliberations: Consensus not reached. MAP
noted that UTI is better defined and the diagnosis more certain than
cellulitis but not as clear as hip or knee replacement surgery for a
resource use measure. According to the measure developer much of the
variation is in the post-acute care. Matching quality measures are
needed. MAP did not reach consensus on a recommendation for the
Value-Based Payment Modifier.
Public comments received: 6
Preliminary Analysis of Measure
- 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? .
- 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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a knee replacement surgery is very clearly
defined and be matched with 3 finalized measures for knee replacement
in PQRS. Conditional on submission to NQF for
endorsement.
- Public comments received: 3
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)).
Measure Specifications
- 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
Summary of Workgroup Deliberations
- Workgroup Recommendation: Conditional support
- Workgroup Rationale: MAP supports this episode-based
payment measure since a spine surgery is very clearly defined. MAP is
pleased to learn that a quality measure being developed for spine
surgery to match this cost measure.
- Public comments received: 4
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)).
Appendix B: Program Summaries
Program Index
Full Program Summaries
Program Type: Pay for Reporting – Performance information is
currently reported to the Centers for Medicare & Medicaid Services
(CMS) but it is expected to be publicly available in the future.
Incentive Structure: Pay for Reporting – Performance
information is currently reported to the Centers for Medicare &
Medicaid Services (CMS) but it is expected to be publicly available in
the future.
Program Goals:
- Promote higher quality, more efficient care for Medicare
beneficiaries.
- Establish a system for collecting and providing quality data to
ASCs.
- Provide consumers with quality of care information that will help
them make informed decisions about their health care.
Critical Program Objectives:
- Include measures that have high impact and are meaningful to
patients.
- Align measures with CMS’ various quality reporting programs,
particularly the Hospital Outpatient Quality Reporting program, to
facilitate comparisons across care settings, and to reduce burden for
facilities that participate in these programs.
- Priority measure gap areas for the ASCQR program include surgical
care quality, infection rates, follow-up after procedures,
complications including anesthesia related complications, cost, and
patient and family engagement measures including an ASC-specific
CAHPS module and patient-reported outcome measures.
Program Update:
- For fiscal year (FY) 2017, CMS proposed the following measure:
OP-32 Facility Seven-Day Risk Standardized Hospital Visit Rate after
Outpatient Colonoscopy
- CMS proposed criteria for determining when a measure is
“topped-out”. Two criteria were proposed: 1) statistically
indistinguishable performance at the 75th and 90th percentiles, and
2) a truncated coefficient of variation less than or equal to
0.10.
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:
- Providing consumers with quality of care information that will
help them make informed decisions about their health care.
- Encourage clinicians to improve the quality of care they provide
to their patients and create incentives to maximize
performance.
Critical Program Objectives:
- Focus on outcome measures and measures that are meaningful to
consumers (i.e., have face validity) and purchasers.
- Focus on patient experience, patient-reported outcomes (e.g.,
functional status), care coordination, population health (e.g., risk
assessment, prevention), and appropriate care measures.
- Public reporting of PQRS measures for:
- Physicians—medicine, osteopathy, podiatric medicine,
optometry, oral surgery, dental medicine, chiropractic
- Practitioners—physician assistant, nurse practitioner,
clinical nurse specialist, certified registered nurse
anesthetist, certified nurse midwife, clinical social worker,
clinical psychologist, registered dietician, nutrition
professional, audiologists
- Therapists—physical therapist, occupational therapist,
qualified speech-language therapist
- Reporting of physicians in groups and ACOs is included.
- NQF-endorsed measures are preferred for public reporting programs
over measures that are not endorsed or are in reserve status (i.e.,
topped out); measures that are not NQF-endorsed should be submitted
for endorsement or removed.
- To generate a comprehensive picture of quality, measure results
should be aggregated (e.g., composite measures), with drill-down
capability for specific measure results.
- Alignment of measures in federal programs.
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:
- PQRS measures
- Patient health outcomes and functional status of patients
- Continuity and coordination of care and care transitions,
including episodes of care and risk-adjusted resource use
- Efficiency
- Patient experience and patient, caregiver, and family engagement
- Safety, effectiveness, and timeliness of care
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:
- PQRS, PQRS GPRO, EHR and Million Hearts: include an indicator of
satisfactory participation
- PQRS GPRO and ACO GPRO: all PQRS GPRO measures for groups of 2 or
more; all measures reported by ACOs with minimum sample size of 20.
- CAHPS for PQRS for all groups of 2 or more and CAHPS for ACOs for
all measures that meet sample size
- PQRS: All PQRS measures for individual EPs collected through
registry, EHR or claims.
- QCRD data: All individual EP-level 2015 QCDR data.
CMS
has indicated an interest in MAP identifying those PQRS measure that are
most meaningful to consumers.
Program Type: Pay for Performance, Public Reporting
Incentive Structure: Under this program, payments to dialysis
facilities are reduced if facilities do not meet or exceed the required
total performance score, which is the sum of the scores for established
individual measures during a defined performance period. Payment
reductions are on a sliding scale, which could amount to a maximum of two
percent per year. Facility performance in the End Stage Renal
Disease Quality Incentive Program (ESRD QIP) is publicly reported through
three mechanisms: Performance Score Certificate, the Dialysis Facility
Compare website, and ESRD QIP Dialysis Facility Performance
Information.
Program Goals: Improve the quality of dialysis care and produce
better outcomes for beneficiaries.
Critical Program Objectives: Statutory Requirements
- Program measure set should include measures of anemia management
that reflect labeling approved by the Food and Drug Administration
(FDA), dialysis adequacy, patient satisfaction, iron management, bone
mineral metabolism, and vascular access.
MAP
Previous Recommendation
- Measure set expand beyond dialysis procedures to include
nonclinical aspects of care such as care coordination, medication
reconciliation, functional status, patient engagement, pain, falls,
and measures covering comorbid conditions such as depression.
- Explore whether the clinically focused measures could be combined
in a composite measure for assessing optimal dialysis care.
Future direction of the Program
- Outcome measures are preferred
- Inclusion of pediatric measures to assess the pediatric
population that has been largely excluded from the existing
measures
- Identify appropriate data elements and sources to support
measures
Program Update:
- Final rule for End-Stage Renal Disease (ESRD) prospective payment
system (PPS) for calendar year (CY) 2015:
- Final measure set for the PY 2017 ESRD QIP
- Continue using measures finalized for the PY 2016 program
measure set except one measure: the Hemoglobin Greater than
12 g/dl, which CMS has finalized to remove because it is
topped out.
- Adopt the Standardized Readmission Ratio (SRR) clinical
measure, which is currently under review by NQF (NQF#2496)
and addresses care coordination. MAP had supported the
direction of the measure concept in the 2013 pre-rulemaking.
- Final measure set for the PY 2018 ESRD QIP
- Continue using measures finalized for the PY 2017 program
measure set with the exception of the ICH CAHPS reporting
measure, which will be converted to a clinical measure, 0258
In-center hemodialysis CAHPS Survey.
- Adopt three new measures which are based on NQF-Endorsed
measures that MAP supported in 2014 (NQF #0420, NQF #0418,
NQF #0431). CMS is finalizing to adopt the following
measures as a reporting measure until such time that they can
collect the baseline data needed to score it as a clinical
measure:
- Pain Assessment and Follow-Up, a reporting measure.
- Depression Screening and Follow-Up, a reporting measure
- NHSN Healthcare Personnel Influenza Vaccination, a
reporting measure
- Adopt two additional new measures including: Percentage
of pediatric peritoneal dialysis patient-months with spKt/V
greater than or equal to 1.8, which was conditionally
supported by MAP in 2014, and Standard Transfusion Ratio
which MAP had supported the direction of in the 2013
pre-rulemaking.
- Dialysis Facility Compare Star Ratings
- CMS has finalized the methodology for its Dialysis Facility
Compare (DFC) Star Rating Program and is providing all
Medicare-participating dialysis facilities a 15 day review period
to review their data and star rating before they are posted on
Dialysis Facility Compare in January 2015.
- The DFC Star Rating is based on the following nine measures,
which will be grouped into three domains for evaluation purposes:
- Standardized Mortality Ratio (SMR) (NQF #0369)
- Standardized Hospitalization Ratio (SHR) (NQF#1463)
- Standardized Transfusion Ratio (STrR)
- Percentage of adult hemodialysis (HD) patients who had
enough wastes removed from their blood during dialysis (NQF
#0249)
- Percentage of pediatric hemodialysis (HD) patients who
had enough wastes removed from their blood during dialysis
(NQF #1423)
- Percentage of adult peritoneal dialysis (PD) patients who
had enough wastes removed from their blood during dialysis
(NQF #0318)
- Percentage of adult dialysis patients who had
hypercalcemia (NQF #1454)
- Percentage of adult dialysis patients who received
treatment through arteriovenous fistula (NQF #0257)
- Percentage of adult patients who had a catheter left in
vein longer than 90 days for their regular hemodialysis
treatment (NQF #0256)
- CMS will stop publicly reporting two quality measures from
the DFC website, the URR dialysis adequacy measure and the
Hemoglobin greater than 12 g/dl. These measures no longer provide
meaningful information because they are topped out.
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:
- NQF-endorsed measures are strongly preferred for
pay-for-performance programs; measures that are not NQF-endorsed
should be submitted for endorsement or removed.
- Include measures that have been reported in a national program
for at least one year (e.g.,PQRS) and ideally can be linked with
particular cost or resource use measures to capture value.
- Focus on outcomes, composites, process measures that are proximal
to outcomes, appropriate care (e.g., overuse), and care coordination
measures (measures included in the MAP Families of Measures generally
reflect these characteristics).
- Monitor for unintended consequences to vulnerable populations
(e.g., through stratification).
Program Update: None
Program Type: Pay-for-Performance and Public Reporting. HAC
scores will be reported on the Hospital Compare website beginning
December 2014.
Incentive Structure:
- The 25% of hospitals that have the highest rates of HACs (as
determined by the measures in the program) will have their Medicare
payments reduced by 1%.
- The measures in the program are classified into two domains:
Domain 1 includes the Patient Safety Indicator (PSI) 90 measure, a
composite of eight administrative claims based measures and Domain 2
includes infection measures developed by the Centers for Disease
Control and Prevention’s (CDC) National Health Safety Network (CDC
NHSN). Each domain will be weighted to determine the total
score.
- In the FY 2014 IPPS/LTCH PPS rule, measures for FY 2015, FY 2016
and FY 2017 HAC Reduction Program were finalized.
- FY 2015: PSI 90 (domain 1) and CDC NHSN’s Central-line
Association Bloodstream Infection (CLABSI and CAUTI measures
(domain 2).
- FY 2016: CDC NHSN surgical site infection measure (infections
following abdominal hysterectomy and colon procedures) will be
added to domain 2
- FY 2017: CDC NHSN MRSA and C. difficile measures will be
added to domain 2.
- The weight that each domain contributes to the total HAC score
has been finalized for FY 2015 and FY 2016.
- FY 2015: Domain 1 is 35% and Domain 2 is 65% of the Total HAC
Score.
- FY 2016: Domain 1 will be 25% and Domain 2 will be 75% of the
Total HAC score.
Program Goals:
- Heighten awareness of HACs and eliminate the incidence of HACs
that could be reasonably prevented by applying evidence-based
clinical guidelines.
- Provide motivation to reduce the incidence of HACs, improve
patient outcomes, and reduce the cost of care.
- Support a broader public health imperative by helping to raise
awareness and action by prompting a national discussion on this
important quality problem.
- Drive improvement for the care of Medicare beneficiaries, but
also privately insured and Medicaid patients, through spill over
benefits of improved care processes within hospitals.
Critical Program Objectives:
- Focus on reducing the major drivers of patient harm.
- Overlap in measures between the HAC Reduction Program and the
Hospital Value-Based Purchasing Program can help to focus attention
on critical safety issues.
- In its 2013-14 round of pre-rulemaking, MAP noted a number of
gaps for this program: PSI-5 to address foreign bodies retained after
surgery, and development of measures to address wrong site/wrong side
surgery and sepsis beyond post-operative infections.
Program Update:
- No new measures were added in the FY 2015 IPPS/LTCH PPS rule to
allow hospitals time to gain experience with the measures that were
finalized in the FY 2014 IPPS/LTCH PPS rule.
- PSI-90 is currently undergoing review by NQF. AHRQ is considering
the addition of three additional measures for the composite, PSI #9
Perioperative Hemorrhage or Hematoma Rate, PSI #10 Postoperative
Physiologic and Metabolic Derangement Rate, and PSI #11 Postoperative
Respiratory Failure Rate. CMS believes this change to be
significant and will propose the change in the rulemaking process
prior to requiring reporting of the revised measure.
- The CDC NHSN CLABSI and CAUTI measures also recently underwent
NQF review. These measures were recommended for continued
endorsement.
Program Type: Pay for Reporting, Public Reporting
Incentive Structure: Medicare-certified home health agencies
(HHAs) are required to collect and submit the Outcome and Assessment
Information Set (OASIS). The OASIS is a group of data elements that
represent core items of a comprehensive assessment for an adult home care
patient and form the basis for measuring patient outcomes for purposes of
outcome-based quality improvement. Home health agencies meet their
quality data reporting requirements through the submission of OASIS
assessments and Home Health CAHPS. HHAs that do not submit data will
receive a 2 percentage point reduction in their annual HH market basket
percentage increase. Subsets of the quality measures generated from OASIS
are reported on the Home Health Compare website, which provides
information about the quality of care provided by HHAs throughout the
country.
Program Goals: As home health quality goals, CMS has adopted
the mission of The Institute of Medicine (IOM) which has defined quality
as having the following properties or domains: effectiveness, efficiency,
equity, patient centeredness, safety, and timeliness.
Critical Program Objectives: Statutory Requirements
- Home health is a covered service under the Part A Medicare
benefit. It consists of part-time, medically necessary skilled care
(nursing, physical therapy, occupational therapy, and speech-language
therapy) that is ordered by a physician.
- Two categories of quality measures used in HH QRP are outcome
measures and process measures. There are three types of outcome
measures used including:
- Improvement measures (i.e., measures describing a patient’s
ability to get around, perform activities of daily living, and
general health);
- Measures of potentially avoidable events (i.e., markers for
potential problems in care); and
- Utilization of care measures (i.e., measures describing how
often patients access other health care resources either while
home health care is in progress or after home health care is
completed).
- The Improving Medicare Post-Acute Care Transformation Act of
2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs :
- Require post-acute care (PAC) providers to report
standardized patient assessment data, data on quality measures,
and data on resource use and other measures
- Require the data to be interoperable to allow for its
exchange among PAC and other providers to give them access to
longitudinal information so as to facilitate coordinated care and
improve Medicare beneficiary outcomes
- Modify PAC assessment instruments applicable to PAC providers
for the submission of standardized patient assessment data on
such providers and enable assessment data comparison across all
such providers
- Applicable PAC programs are defined as: 1)HHA Quality
Reporting Program; 2) newly required SNF Quality Reporting
Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality
Reporting Program
- Specifies requirements for the creation and reporting of new
quality measures which will be implemented in a staggered time
frame by PAC providers.
- New quality measures will address, at a minimum, the
following domains:
- functional status and changes in function;
- skin integrity and changes in skin integrity;
- medication reconciliation;
- incidence of major falls; and
- accurately communicating health information and care
preferences when a patient is transferred
- Resource use measures will address the following:
- efficiency measures to include total Medicare spending
per beneficiary;
- discharge to community; and
- risk adjusted hospitalization rates of potentially
preventable admissions and readmissions.
- Directs the Secretary to: (1) provide confidential feedback
reports to PAC providers on their performance with respect to
required measures by October 1, 2017 for SNF, IRF, and LTCH and
January 1, 2018 for HHA ; and (2) arrange for public reporting of
PAC provider performance on quality, resource use, and other
measures by October 1, 2018 for SNF, IRF, and LTCH and
January 1, 2019 for HHA.
MAP Previous Recommendation
- MAP noted that the large measure set reflects the heterogeneity
of home health population; however, the measure set could be more
parsimonious.
Future Direction of the
Program
- CMS will conduct a thorough analysis of the measure set to
identify priority gap areas, measures that are topped out, and
opportunities to improve the existing measures.
Program Update:
- Updates listed in the CY 2015 Home Health Final Rule:
- Specified the adoption of two claims based measures in the CY
2014 HH PPS final rule and the beginning date of CY 2014 for
reporting. These claims based measures supported by MAP in the
past pre-rulemaking cycle are: (1) Rehospitalization during the
first 30 days of HH; and (2) Emergency Department Use without
Hospital Readmission during the first 30 days of HH. These
measures will be added to HH Compare for public reporting in CY
2015.
- Set a date of October 2014 for removal of the 9 episode
stratified process measures in the CASPER reports. In addition,
five short stay measures which had previously been reported on HH
Compare were recently removed from public reporting and replaced
with non-stratified “all episodes of care” versions of these
measures.
- Finalized a new pay-for-reporting performance requirement for
OASIS reporting. For episodes beginning on or after July
1st, 2015 and before June 30th, 2016, HHAs must score at least 70
percent on the Quality Assessments Only (QAO) metric of
pay-for-reporting performance requirement or be subject to a 2
percentage point reduction to their market basket update for CY
2017.
- Will continue to require HHCAHPS
Program Type: Pay for Reporting, Public Reporting
Incentive Structure: Failure to submit required quality data,
beginning in FY 2014 and for each year thereafter, shall result in a 2
percentage point reduction to the market basket percentage increase for
that fiscal year. The data must be made publicly available,
with Hospice Programs having an opportunity to review the data prior to
its release. No date has been specified to begin public reporting of
hospice quality data.
Program Goals: Hospice care uses an interdisciplinary approach
to deliver medical, nursing, social, psychological, emotional, and
spiritual services through the use of a broad spectrum of professional
and other caregivers and volunteers. The goal of hospice care is to make
the hospice patient as physically and emotionally comfortable as
possible, with minimal disruption to normal activities, while remaining
primarily in the home environment.
Critical Program Objectives: Statutory Requirements
- As of July 1, 2014, all Medicare-certified hospices are required
to submit an HIS-Admission record and HIS-Discharge record for each
patient admission to their hospice.
- The HIS is a patient-level data collection tool developed as
part of the HQRP, which can be used to collect data to calculate
6 National Quality Forum-endorsed (NQF) Measures and 1 modified
NQF Measure:
- NQF #1617 Patients Treated with an Opioid who are Given a
Bowel Regimen
- NQF #1634 Pain Screening
- NQF #1637 Pain Assessment
- NQF #1638 Dyspnea Treatment
- NQF #1639 Dyspnea Screening
- NQF #1641 Treatment Preferences
- Modified NQF #1647 Beliefs/Values Addressed (if desired
by the patient)
MAP Previous Recommendation
- Include measures addressing concepts such as goal attainment,
patient engagement, care coordination, depression, caregiver’s role,
and timely referral to hospice.
Future
Direction of the Program
- Develop an outcome measure addressing pain.
- Select measures that address care coordination, communication,
timeliness/responsiveness of care, and access to the healthcare team
on a 24-hour basis.
Program Update:
- FY 2015 Hospice Final Rule:
- CMS finalized the Hospice Item Set (HIS) in last year’s rule
to meet the quality reporting requirements for hospices for the
FY 2016 payment determination (data submission takes effect on or
after July 1, 2014) and each subsequent year. HIS to be used by
all hospices to collect and submit standardized data items about
each patient admitted to hospice.
- The CAHPS Hospice Survey has a Jan 1, 2015 implementation
date. (Participation requirements for the survey begin January 1,
2015 for the FY 2017 annual payment update.)
Program Type: Pay for Performance and Public Reporting –
Payments are based on information publicly reported on the Hospital
Compare website.
Incentive Structure: Diagnosis-related group (DRG) payment
rates will be reduced based on a hospital’s ratio of actual to expected
readmissions. The maximum payment reduction is 2 percent, and will
increase to 3% beginning October 2014.
Program Goals:
- Reduce readmissions in acute care hospitals paid under the
Inpatient Prospective Payment System (IPPS), which is approximately
4000 hospitals in the U.S.
- Provide consumers with quality of care information that will help
them make informed decisions about their health care. Hospitals’
readmissions information, including their risk-adjusted readmission
rates, is available on the Hospital Compare website.
Critical Program Objectives:
- Reduce the number of admissions to an acute care hospital
following discharge from the same or another acute care
hospital.
- Engage patients and their families as partners in care.
- Improve patient care and reduce overall healthcare costs.
- Exclude planned readmissions from the measures in the program.
- Encourage hospitals to take a leadership role in improving care
beyond their walls through care coordination across providers since
the causes of readmissions are complex and multifactorial.
- Improve care transitions by decreasing readmission rates through
optimizing processes under the hospital’s control. For example,
improving communication of important inpatient information to those
who will be taking care of the patient post-discharge.
- Acknowledge that factors affecting readmissions are complex, and
may include environmental, community-level, and patient-level
factors, including socio-demographic factors.
- Recognize that multiple entities across the health care system,
including hospitals, post-acute care facilities, skilled nursing
facilities, and others, all have a responsibility to ensure high
quality care transitions to reduce unplanned readmissions to acute
care hospitals.
Program Update:
- The Hospital 30-day, all-cause, unplanned, risk-standardized
readmission rate (RSRR) following Coronary Artery Bypass Graft (CABG)
Surgery was added to the program measure set for implementation in FY
2017.
- The planned readmission algorithm for the acute myocardial
infarction, heart failure, pneumonia, chronic obstructive pulmonary
disease, and total hip arthroplasty/ total knee arthroplasty measures
was updated.
Program Type: Pay for Performance
Incentive Structure: Medicare bases a portion of hospital
reimbursement on performance through the Hospital Value-Based Purchasing
Program (VBP). Medicare withholds its regular hospital reimbursements
from all hospitals paid under its inpatient prospective payment system
(IPPS) to fund a pool of VBP incentive payments. The amount withheld from
reimbursements increases over time:
- FY 2015: 1.5%
- FY 2016: 1.75%
- FY 2017 and future fiscal years: 2%
Hospitals are scored
based on their performance on each measure within the program relative to
other hospitals as well as on how their performance on each measure has
improved over time. The higher of these scores on each measure is used in
determining incentive payments.
Measures selected for the VBP
program must be included in IQR and reported on the Hospital Compare
website for at least 1 year prior to use in the VBP program.
Program Goals:
- Improve healthcare quality by realigning hospitals’ financial
incentives.
- Provide incentive payments to hospitals that meet or exceed
performance standards.
Critical Program Objectives:
- Include measures where there is a need and opportunity for
improvement.
- Emphasize areas of critical importance for high performance and
quality improvement, and ideally, link clinical quality and cost
measures to capture value.
- NQF-endorsed measures are strongly preferred.
- Keep the program measure set parsimonious to avoid diluting the
payment incentives.
- MAP identified a number of gap areas that should be addressed
within the VBP program measure set, including medication errors,
mental and behavioral health, emergency department throughput, a
hospital’s culture of safety, and patient and family
engagement.
Program Update:
- For the FY 2017 Measure Set:
- Six measures were removed from the FY 2017 program measure
set because they were topped out.
- Three additional measures were added to the program measure
set: NQF#0469 PC-01 Elective Delivery Prior to 39 Weeks
Gestation, NQF #1716 Methicillin-Resistant Staphylococcus aureus
(MRSA) Bacteremia, and NQF #1717 Clostridium difficile (C.
difficile) Infection
- For the FY 2019 Measure Set:
- NQF #1550 Hospital-level Risk-Standardized Complication Rate
(RSCR) Following Elective Primary Total Hip Arthroplasty (THA)
and Total Knee Arthroplasty (TKA) was added to the program
measure set.
Program Type: Pay for Reporting – Information will be reported
on the Hospital Compare website.
Incentive Structure:
- Inpatient psychiatric hospitals or psychiatric units that do not
report data on the required measures will receive a 2 percent
reduction in their annual federal payment update.
- The IPFQR Program applies to freestanding psychiatric hospitals,
government-operated psychiatric hospitals, and distinct psychiatric
units of acute care hospitals and critical access hospitals that are
paid under the Medicare IPF prospective payment system. This program
does not apply to children’s hospitals, which are paid under a
different system.
Program Goals:
- Provide consumers with quality information to help inform their
decisions about their healthcare options.
- Improve the quality of inpatient psychiatric care by ensuring
providers are aware of and reporting on best practices.
- Establish a system for collecting and providing quality data for
inpatient psychiatric hospitals or psychiatric units.
Critical Program Objectives:
- Ensure measures in the program are meaningful to patients.
- Improve person-centered psychiatric care, such as assessing
patient and family/caregiver experience and engagement and
establishing relationships with community resources, are priority
measure gap areas.
- Measure gaps in the IPFQR program include step down care,
behavioral health assessments and care in the ED, readmissions,
identification and management of general medical conditions, partial
hospitalization or day programs, and a psychiatric care module for
CAHPS.
Program Update:
- For FY 2016:
- Two structural measures regarding routine assessment of
patient experience of care and use of an electronic health record
were added to the program measure set for FY 2016.
- For FY 2017:
- NQF #1654 Tobacco Use Treatment Provided or Offered (TOB-2)
and Tobacco Use Treatment (TOB-2a) was added to the program
measure set.
- Two influenza measures, NQF #0431 Influenza Vaccination
Coverage Among Healthcare Personnel and #1659 Influenza
Immunization were added to the program measure set.
Program Type: Pay-for-Reporting and Public Reporting. A subset
of the measures in the program are publicly reported on the Hospital
Compare web site.
Incentive Structure: Hospitals that do not report data on the
required measures will receive a 2 percent reduction in their annual
Medicare payment update.
Program Goals:
- Provide an incentive for hospitals to publicly report quality
information about their services
- Provide consumers information about hospital quality so they can
make informed choices about their care.
Critical Program Objectives:
- Choose high impact measures that will improve both quality and
efficiency of care and are meaningful to consumers.
- Move towards more outcome measures rather than structure or
process measures.
- Align reporting requirements with other clinical programs where
appropriate to reduce the burden on providers and support efficient
use of measurement resources.
- Engage patients and families as partners in their care.
- Expand the program to include measures that allow rural and other
small hospitals to participate.
- In the 2013-14 pre-rulemaking process, MAP recommended the rapid
filling of the following fairly extensive gap list for this program:
pediatrics, maternal/child health, cancer, behavioral health,
affordability/cost, care transitions, patient education, palliative
and end of life care, medication reconciliation, a culture of safety,
pressure ulcer prevention, and adverse drug events. MAP suggested
that HHS could look to existing measures in the PPS-Exempt Cancer
Hospital Quality Reporting Program, the Inpatient Psychiatric
Facility Quality Reporting Program, and Hospice Quality Reporting
Programs to begin to fill these gaps
Program Update:
- For FY 2017, CMS has finalized a total of 63 measures for the
program measure set.
- 11 new measures were added for FY 2017.
- These measures address coronary artery bypass graft
(CABG) surgery readmissions and mortality, pneumonia and
heart failure episode of care payments, severe sepsis and
septic shock management, newborn screening for hearing,
exclusive breast feeding, child asthma home management plan
of care, and healthy term newborns.
- Two measures were readopted as voluntary electronic
clinical quality measures to support alignment with the
Medicare EHR Incentive Program for Eligible Hospitals and
Critical Access Hospitals. These measures are NQF #0142
AMI-2 Aspirin Prescribed at Discharge and NQF #0639 AMI-10
Statin Prescribed at Discharge.
- 19 measures were removed for FY 2017. These measures
were removed because they were topped out. However, to
continue aligning the IQR and Medicare EHR Incentive Program, 10
measures will be retained on a voluntary basis to allow hospitals
an opportunity to test the accuracy of the electronic health
record reporting systems.
Program Type: Pay for Reporting, Public Reporting
Incentive Structure: For fiscal year of 2014, and each year
thereafter, Inpatient Rehabilitation Facility providers (IRFs) must
submit data on quality measures to the Centers for Medicare &
Medicaid Services (CMS) to receive annual payment updates. Failure to
report quality data will result in a 2 percent reduction in the annual
increase factor for discharges occurring during that fiscal year.
The data must be made publicly available, with IRF providers having an
opportunity to review the data prior to its release. No date has been
specified to begin public reporting of quality data.
Program Goals: Address the rehabilitation needs of the
individual including improved functional status and achievement of
successful return to the community post-discharge.
Critical Program Objectives: Statutory Requirements
- Measures should align with the National Quality Strategy (NQS),
be relevant to the priorities of IRFs (such as patient safety,
reducing adverse events, better coordination of care, and person- and
family-centered care.
- The Improving Medicare Post-Acute Care Transformation Act of
2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs :
- Require post-acute care (PAC) providers to report
standardized patient assessment data, data on quality measures,
and data on resource use and other measures
- Require the data to be interoperable to allow for its
exchange among PAC and other providers to give them access to
longitudinal information so as to facilitate coordinated care and
improve Medicare beneficiary outcomes
- Modify PAC assessment instruments applicable to PAC providers
for the submission of standardized patient assessment data on
such providers and enable assessment data comparison across all
such providers
- Applicable PAC programs are defined as: 1)HHA Quality
Reporting Program; 2) newly required SNF Quality Reporting
Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality
Reporting Program
- Specifies requirements for the creation and reporting of new
quality measures which will be implemented in a staggered time
frame by PAC providers.
- New quality measures will address, at a minimum, the
following domains:
- functional status and changes in function;
- skin integrity and changes in skin integrity;
- medication reconciliation;
- incidence of major falls; and
- accurately communicating health information and care
preferences when a patient is transferred
- Resource use measures will address the following:
- efficiency measures to include total Medicare spending
per beneficiary;
- discharge to community; and
- risk adjusted hospitalization rates of potentially
preventable admissions and readmissions.
- Directs the Secretary to: (1) provide confidential feedback
reports to PAC providers on their performance with respect to
required measures by October 1, 2017 for SNF, IRF, and LTCH and
January 1, 2018 for HHA ; and (2) arrange for public reporting of
PAC provider performance on quality, resource use, and other
measures by October 1, 2018 for SNF, IRF, and LTCH and
January 1, 2019 for HHA.
MAP Previous Recommendation
- Program measure set is too limited and could be enhanced by
addressing core measure concepts not currently addressed in the set
such as care coordination, functional status, and medication
reconciliation and the safety issues that have high incidence in
IRFs, such as MRSA, falls, CAUTI, and C. difficile.
Program Update:
- IRF Prospective Payment System for Federal Fiscal Year 2015 final
rule:
- For the FY 2017 adjustments to the IRF PPS annual increase
factor, in addition to retaining the previously finalized
measures, CMS adopted two new quality measures:
- Measure NQF#1717 NHSN Facility-wide Inpatient
Hospital-onset Clostridium difficile Infection (CDI) Outcome
Measure (supported by MAP in the 2014 pre-rulemaking
report)
- Measure NQF #1716 NHSN Facility-wide Inpatient
Hospital-onset Methicillin-resistant Staphylococcus aureus
(MRSA) Bacteremia Outcome Measure (conditionally supported by
MAP in the 2014 pre-rulemaking report)
Program Type: Pay for Reporting, Public Reporting
Incentive Structure: For fiscal year 2014, and each year
thereafter, Long-Term Care Hospital providers (LTCHs) must submit data on
quality measures to the Centers for Medicare & Medicaid Services
(CMS) to receive full annual payment updates; failure to report quality
data will result in a 2 percent reduction in the annual payment
update. The data must be made publicly available, with LTCH
providers having an opportunity to review the data prior to its release.
No date has been specified to begin public reporting of quality
data.
Program Goals: Furnishing extended medical care to individuals
with clinically complex problems (e.g., multiple acute or chronic
conditions needing hospital-level care for relatively extended periods of
greater than 25 days).
Critical Program Objectives: Statutory Requirements
- Measures should align with the National Quality Strategy (NQS),
promote enhanced quality with regard to the priorities most relevant
to LTCHs (such as patient safety, better coordination of care, and
person- and family-centered care).
- The Improving Medicare Post-Acute Care Transformation Act of
2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs :
- Require post-acute care (PAC) providers to report
standardized patient assessment data, data on quality measures,
and data on resource use and other measures
- Require the data to be interoperable to allow for its
exchange among PAC and other providers to give them access to
longitudinal information so as to facilitate coordinated care and
improve Medicare beneficiary outcomes
- Modify PAC assessment instruments applicable to PAC providers
for the submission of standardized patient assessment data on
such providers and enable assessment data comparison across all
such providers
- Applicable PAC programs are defined as: 1)HHA Quality
Reporting Program; 2) newly required SNF Quality Reporting
Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality
Reporting Program
- Specifies requirements for the creation and reporting of new
quality measures which will be implemented in a staggered time
frame by PAC providers.
- New quality measures will address, at a minimum, the
following domains:
- functional status and changes in function;
- skin integrity and changes in skin integrity;
- medication reconciliation;
- incidence of major falls; and
- accurately communicating health information and care
preferences when a patient is transferred
- Resource use measures will address the following:
- efficiency measures to include total Medicare spending
per beneficiary;
- discharge to community; and
- risk adjusted hospitalization rates of potentially
preventable admissions and readmissions.
- Directs the Secretary to: (1) provide confidential feedback
reports to PAC providers on their performance with respect to
required measures by October 1, 2017 for SNF, IRF, and LTCH and
January 1, 2018 for HHA ; and (2) arrange for public reporting of
PAC provider performance on quality, resource use, and other
measures by October 1, 2018 for SNF, IRF, and LTCH and
January 1, 2019 for HHA.
MAP Previous
Recommendation
- Functional status assessment should cover a broad range of
mobility issues, such as position changes, locomotion, poor mobility,
picking up objects, and chair-to-bed transfers.
- Increased attention should be given to pain, agitation, and
delirium among the ventilated population, as these factors are the
biggest impediments to mobility.
- Add measures to address cost, cognitive status assessment (e.g.,
dementia identification), medication management (e.g., use of
antipsychotic medications), and advance directives.
Program Update:
- Hospital Inpatient Prospective Payment System for Acute Care
Hospitals and the Long-Term Care Hospital Prospective Payment System
FY 2015 Final Rule:
- For the FY 2018 payment determination and subsequent years,
in addition to retaining the previously finalized measures, CMS
adopted three new quality measures:
- Percent of LTCH patients with an admission and discharge
functional assessment and a care plan that addresses function
(conditionally supported by MAP in the 2014 pre-rulemaking
report )
- Functional Outcome Measure: change in mobility among
patients requiring ventilator support (conditionally
supported by MAP in the 2014 pre-rulemaking report)
- Ventilator-Associated Event (supported by MAP in the 2014
pre-rulemaking report)
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:
- Improve the overall health for a population of Medicare
Fee-For-Service (FFS) beneficiaries and ensuring that care
improvements and health outcomes are widely shared across
subpopulations;
- Improve quality and health outcomes while lowering 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), measures that span
different parts of the life span and different types of patients
(such as including end of life or patients receiving palliative
care), and measures that span across settings;
- Promote alignment across other quality measurement reporting
programs;
- Include more high-value measures such as:
- Patient-reported outcome measures in the areas of depression
remission, functional status, and smoking;
- Patient-reported outcome measures for medically complex
patients (e.g., chronically ill or those with multiple chronic
conditions);
- Measure of health risks with follow-up interventions;
- Cost and resource use measures; and
- Appropriate use measures.
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:
- Modifying the measure set (added 8 measures, retired/replaced
8) to be more outcome-oriented and reduce the reporting burden
on ACOs;
- Modifying benchmarking approach for topped-out measures;
- Interest in aligning with physician programs (like Value-Based
Payment Modifier and EHR incentive program);
- Finalized that CMS will award ACOs for quality improvement and
that ACOs entering their second or subsequent agreement period will
be assessed on the quality performance standard that would otherwise
apply to an ACO if It were in the third performance year of the first
agreement; and
- Sought input on (proposed rule):
- Measures that might be used to assess the ACO’s performance
with respect to care coordination in post-acute care and other
settings;
- Specific caregiver experience of care measures that might be
considered in future rulemaking;
- Suggestions of new measures of the quality of care furnished
to the frail elderly population; and
- Measures/tools to assess changes in physical and mental
health over time.
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:
- Medicare: Up to $44,000 over 5 continuous years. The last year to
begin the program is 2014. Penalties take effect in 2015 and in each
year hereafter where EPs are eligible but do not participate.
- Medicaid: Up to $63,750 over 6 years. The last year to begin the
program is in 2016. Payment adjustments do not apply to Medicaid.
Program Goals:
- Promote widespread adoption of certified EHR technology by
providers.
- Incentivize “meaningful use” of EHRs by providers to:
- Improve quality, safety, efficiency, and reduce health
disparities
- Engage patients and family
- Improve care coordination, and population and public
health
- Maintain privacy and security of patient health
information
Critical Program Objectives:
- Include endorsed measures that have eMeasure specifications
available.
- Over time, as health IT becomes more effective and interoperable,
focus on:
- Measures that reflect efficiency in data collection and
reporting through the use of health IT
- Measures that leverage health IT capabilities (e.g., measures
that require data from multiple settings/providers,
patient-reported data, or connectivity across platforms to be
fully operational)
- Innovative measures made possible by the use of health IT
- Alignment with other federal programs, particularly PQRS.
Program Update:
- The three main components of Meaningful Use:
- The use of a certified EHR in a meaningful manner, such as
e-prescribing;
- The use of certified EHR technology for electronic exchange
of health information to improve quality of healthcare; and
- The use of certified EHR technology to submit clinical
quality and other measures.
- Meaningful Use Stage 2:
- The earliest providers will demonstrate Stage 2 of meaningful
use is 2014.
- For Stage 2 (2014 and beyond): Eligible Professionals must
report on 9 total clinical quality measures that cover 3 of the
National Quality Strategy Domains (selected from a set of 64
clinical quality measures).
- CMS is not requiring the submission of a core set of
electronic CQMs (eCQMs). Instead, CMS has identified two
recommended core sets of eCQMs—one for adults and one for
children—that focus on high-priority health conditions and
best-practices for care delivery.
- The program has several options that align with other
programs:
- Report individual eligible professionals’ eCQMs through PQRS
Portal
- Report group’s eCQMs through PQRS Portal
- Report group’s eCQMs through Pioneer ACO participation or
Comprehensive Primary Care Initiative participation.
- Measures under consideration for the current pre-rulemaking cycle
are for Meaningful Use Stage 3. CMS has determined that the measures
under consideration (MUC) for the EHR Incentive Programs are
appropriately specified as “electronic Clinical Quality Measures
(eCQMs)” or “eMeasures”. While some testing may have been done, the
eMeasures under consideration are being revised to meeting the most
recent standards and have not been used in the field. CMS
agrees the eCQMs on the MUC list are “Measures Under
Development”.
Program Type: Pay for Reporting. The Medicare and Medicaid EHR
Incentive Programs provide incentives to eligible professionals, eligible
hospitals, and critical access hospitals (CAHs) as they adopt, implement,
upgrade, or demonstrate meaningful use of certified EHR technology
Incentive Structure: For the Medicare Incentive Program
(hospitals), incentive payments began in 2011 and are comprised of an
Initial Amount, Medicare Share, and Transition Factor. The CAH EHR
Incentive payment is based on a formula for Allowable Costs and the
Medicare Share. The Medicaid Incentive program includes an Overall EHR
Amount and Medicaid Share. Medicare payment penalties will take effect in
2015 for providers who are eligible but do not participate. Payment
penalties do not apply to Medicaid. For Stage 1, eligible facilities must
report on all 15 total clinical quality measures. For Stage 2 (2014 and
beyond) eligible facilities must report on 16 clinical quality
measures that cover 3 of the National Quality Strategy domains. Measures
are selected from a set of 29 clinical quality measures that includes the
15 measures from Stage 1.
Program Goals:
- Promote widespread adoption of certified EHR technology by
providers.
- Incentivize “meaningful use” of EHRs by hospitals to:
- Improve quality, safety, efficiency, and reduce health
disparities
- Engage patients and family
- Improve care coordination, and population and public
health
- Maintain privacy and security of patient health
information
Critical Program Objectives:
- Preference should be given to NQF-endorsed quality measures.
- Select measures that represent the future of measurement
(facilitating information exchange between institutions and
longitudinal tracking of care, such as measures that monitor
incremental changes in a patient’s condition over time).
- Align the measure set with other hospital performance measurement
programs.
- Ensure e-measures in the program are reliable and provide
comparable results to paper-based measures.
Program Update:
- The three main components of Meaningful Use:
- The use of a certified EHR in a meaningful manner, such as
e-prescribing;
- The use of certified EHR technology for electronic exchange
of health information to improve quality of healthcare; and
- The use of certified EHR technology to submit clinical
quality and other measures.
- For Stage 1 (2014):
- Removal of clinical quality measures (CQMs) as a separate
core objective for Stage 1 for eligible professionals, eligible
hospitals, and CAHs. Reporting CQMs will still be required in
order to achieve meaningful use.
- For Stage 2 (2014):
- The earliest Hospitals and Critical Access Hospitals will
demonstrate Stage 2 of meaningful use is October 2014.
- For Stage 2 (2014 and beyond):
- Eligible hospitals and CAHs must meet 16 core objectives and
3 menu objectives that they select from a total list of 6, or a
total of 19 core objectives.
- New Core Objective: Automatically track medications from
order to administration using assistive technologies in
conjunction with an electronic medication administration record
(eMAR)
Program Type: Pay for Reporting – Information on measures is
reported on the Hospital Compare website.
Incentive Structure: Hospitals that do not report data on the
required measures will receive a 2 percent reduction in their annual
Medicare payment update.
Program Goals:
- Establish a system for collecting and providing quality data to
hospitals providing outpatient services such as clinic visits,
emergency department visits, and critical care services.
- Provide consumers with quality of care information that will help
them make informed decisions about their health care.
Critical Program Objectives:
- Focus on measures that have high impact and support national
priorities
- Align the OQR measures with ambulatory care measures
- Specific gap areas for the OQR program measure set include
measures of emergency department (ED) overcrowding, wait times, and
disparities in care—specifically, disproportionate use of EDs by
vulnerable populations. Other gaps include measures of cost,
patient-reported outcomes, patient and family engagement, follow-up
after procedures, fostering important ties to community resources to
enhance care coordination efforts, and an outpatient CAHPS
module.
Program Update:
- For FY 2017, CMS proposed the following measure: OP-32 Facility
Seven-Day Risk Standardized Hospital Visit Rate after Outpatient
Colonoscopy
- CMS proposed criteria for determining when a measure is
”topped-out”. Two criteria were proposed: 1) statistically
indistinguishable performance at the 75th and 90th percentiles and 2)
a truncated coefficient of variation less than or equal to 0.10.
- CMS proposed removal of the following measures:
- OP-4 Aspirin on arrival
- OP-6 Timing to Prophylactic Antibiotics
- OP-7 Prophylactic Antibiotic Selection for Surgical
Patients
Program Type: Reporting: Information will be publicly reported
beginning in 2014.
Incentive Structure: There is currently no financial incentive
for the 11 hospitals in this program to report quality measures. CMS
plans to create an incentive structure in the future.
Program Goals:
- Provide information about the quality of care in cancer
hospitals, in particular the 11 cancer hospitals that are exempt from
the Inpatient Prospective Payment System and the Inpatient Quality
Reporting Program.
- Encourage hospitals and clinicians to improve the quality of
their care, to share information, and to learn from each other’s
experiences and best practices
Critical Program Objectives:
- Include measures appropriate to cancer hospitals that reflect the
highest priority services provided by these hospitals.
- Align measures with the Inpatient Quality Reporting Program and
Outpatient Quality Reporting Program where appropriate and relevant.
- The measures should address gaps in cancer care quality.
MAP has previously identified pain screening and management, patient
and family/caregiver experience, patient-reported symptoms and
outcomes, survival, shared decision making, cost, care coordination
and psychosocial/supportive services as gap areas for this
program
Program Update:
- NQF #1822 External Beam Radiotherapy for Bone Metastases was
added to the program beginning in October 2017. MAP supported this
measure for the PCHQR program, noting that it helps to fill a gap in
palliative care.
- CMS noted that future measure topics may include patient-centered
care planning and care coordination, shared decision making, measures
of quality of life outcomes, and measures of admissions for
complications of cancer and treatment for cancer.
- CMS will make the results of NQF #220 Adjuvant Hormonal Therapy
publicly available in 2015. The results of NQF #138 NHSN
Catheter-Associated Urinary Tract Infections (CAUTI) Outcome Measure
and NQF #139 NHSN Central Line-Associated Bloodstream Infection
(CLABSI) Outcome measure will be made available by 2017.
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:
- To encourage widespread participation many measures are needed
for the variety of EPs specialties and sub-specialties.
- The measures chosen by EPs to submit for PQRS will be reported on
Physician Compare and used to determine the Value Based Payment
Modifier, therefore all PQRS measures will be used for accountability
purposes.
- Include more high value measures, e.g., outcomes,
patient-reported outcomes, composites, intermediate outcomes, process
measures close to outcomes, cost and resource use measures,
appropriate use measures, care coordination measures, patient safety,
etc.
- Include NQF-endorsed measures relevant to clinician reporting to
encourage engagement Measures selected for the program that are not
NQF-endorsed should be submitted for endorsement.
- For measures that are not endorsed, include measures under
consideration that are fully specified and that:
- Support alignment (e.g., measures used in other programs,
registries)
- Are outcome measures that are not already addressed by
outcome measures included in the program
- Are clinically relevant to specialties/subspecialties that do
not currently have clinically relevant measures
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:
- Participation increased from 29% of EPs in 2011 to 36% of EPs in
2012.
- PQRS participation is highest among EPs who see the most Medicare
patients.
- Emergency physicians (64%) and anesthesiology (57%) had the high
participation rates among the specialties using the individual claims
reporting mechanism.
- Internal medicine and family practice had the highest numbers of
EPs participating via the registry mechanism.
- Family practice, internal medicine, nurse practitioner, and
cardiology were also the top four specialties using the EHR reporting
mechanism.
The final 2015 Physician Fee Schedule rule
includes the following updates:
- Beginning in 2015, a downward payment adjustment of -2 percent
will apply to EPs who do not satisfactorily report data on quality
measures for covered professional services or satisfactorily
participate in a qualified clinical data registry
- Identification of 19 cross-cutting measures that can be used by
all EPs – based on the recommendation of a core set from the
MAP.
- For the 12-month reporting period (2015) for the 2017 PQRS
payment adjustment EPs reporting by claims, EHR or registry would
report at least 9 measures, covering at least 3 of the National
Quality Strategy domains.
- For individual EPs reporting via EHR: if the EHR does not
contain data for 9 measures, then report on all measures with
Medicare patient data (aligns with Medicare EHR Incentive
Program).
- Qualified Clinical Data Registries (QCDRs) must report at
least 2 outcome measures or 1 outcome and 1 other (resource use,
patient experience with care, efficiency/appropriate use or
patient safety) measure; QCRDs may report up to 30 non-PQRS
measures; QCRDs must public report measure results beginning in
2015 (except new measures that are not required to report in the
first year)
- Group practices of 100 or more EPs that report via PQRS must
report CAHPS for PQRS GPRO
- Changes to the total number of PQRS measures:
- Addition of 20 new individual measures and two measures
groups to fill existing measure gaps;
- Removal of 50 measures for a variety of reasons:
- Measure steward will no longer maintain the measure
- Performance rates consistently close to 100%, i.e.,
“topped out”
- Measure does not add clinical value to PQRS
- Measures a standard of care
- Evidence and guideline change
- Duplicative measures
- The measures to be removed include 8 hypertension measures, 3
stroke measures, 4 back pain measures, , 4 inflammatory bowel
disease measures, 3 emergency medicine measures
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:
- Measures that are not duplicative of existing or proposed
measures.
- Measures that are further along in development than a measure
concept.
- CMS is not accepting claims-based-only reporting measures.
- Measures that are outcome-based rather than clinical process
measures.
- Measures that address patient safety and adverse events.
- Measures that identify appropriate use of diagnosis and
therapeutics.
- Measures that include the NQS domains of care coordination,
communication, patient experience and patient-reported outcomes.
- Measures that address efficiency, cost and resource use.
Program Type: Public Reporting
Incentive Structure: Skilled nursing facilities (SNFs) and
nursing facilities (NFs) are required to be in compliance with the
requirements in 42 CFR Part 483, Subpart B, to receive payment under the
Medicare or Medicaid programs. Part of this requirement includes
completing the Minimum Data Set (MDS), a clinical assessment of all
residents in Medicare- or Medicaid-certified nursing facilities. Quality
measures are reported on the Nursing Home Compare website using a
Five-Star Quality Rating System, which assigns each nursing home a rating
of 1 to 5 stars, with 5 representing highest standard of quality,
and 1 representing the lowest.
Program Goals: The overall goal of NHQI is to improve the
quality of care in nursing homes using CMS’ informational tools. The
objective of these informational tools is to share quality information
with consumers, health care providers, intermediaries and other key
stakeholders to help them make informed decisions about nursing home care
(e.g., Nursing Home Compare, Nursing Home Checklist).
Critical Program Objectives: Statutory Requirements
- The Improving Medicare Post-Acute Care Transformation Act of
2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs :
- Require post-acute care (PAC) providers to report
standardized patient assessment data, data on quality measures,
and data on resource use and other measures
- Require the data to be interoperable to allow for its
exchange among PAC and other providers to give them access to
longitudinal information so as to facilitate coordinated care and
improve Medicare beneficiary outcomes
- Modify PAC assessment instruments applicable to PAC providers
for the submission of standardized patient assessment data on
such providers and enable assessment data comparison across all
such providers
- Applicable PAC programs are defined as: 1)HHA Quality
Reporting Program; 2) newly required SNF Quality Reporting
Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality
Reporting Program
- Establishes a new “SNF Quality Reporting Program” at the
start of FY 2019 and directs the Secretary to reduce by 2% the
update to the market basket percentage for skilled nursing
facilities which do not report assessment and quality data under
this program.
- Specifies requirements for the creation and reporting of new
quality measures which will be implemented in a staggered time
frame by PAC providers.
- New quality measures will address, at a minimum, the
following domains:
- functional status and changes in function;
- skin integrity and changes in skin integrity;
- medication reconciliation;
- incidence of major falls; and
- accurately communicating health information and care
preferences when a patient is transferred
- Resource use measures will address the following:
- efficiency measures to include total Medicare spending
per beneficiary;
- discharge to community; and
- risk adjusted hospitalization rates of potentially
preventable admissions and readmissions.
- Directs the Secretary to: (1) provide confidential feedback
reports to PAC providers on their performance with respect to
required measures by October 1, 2017 for SNF, IRF, and LTCH and
January 1, 2018 for HHA; and (2) arrange for public reporting of
PAC provider performance on quality, resource use, and other
measures by October 1, 2018 for SNF, IRF, and LTCH and January 1,
2019 for HHA.
- The Protecting Access to Medicare Act of 2014 (PAMA) :
- Directs the Secretary to establish a skilled nursing facility
value-based purchasing (SNF VBP) program under which value-based
incentive payments are made in a fiscal year to skilled nursing
facilities, beginning in fiscal year 2019.
- Readmission measure - Not later than October 1, 2015, the
Secretary shall specify a skilled nursing facility all-cause
all-condition hospital readmission measure (or any successor to
such a measure).
- Resource use measure – Not later than October 1, 2016, the
Secretary shall specify a measure to reflect an all-condition
risk-adjusted potentially preventable hospital readmission rate
for skilled nursing facilities.
- Directs the Secretary to: (1) provide confidential feedback
reports to SNFs on their performance with respect to above
measures, beginning October 1, 2016 and every quarter thereafter;
and (2) establish procedures for making available to the public
by posting on the Nursing Home Compare Medicare website (or a
successor website) information on the performance of SNF with
respect to the above measures beginning not later than October 1,
2017.
MAP Previous Recommendation
- Determine whether (1) there are opportunities to combine the
long-stay and short-stay measures using risk adjustment and/or
stratification to account for patient variations and (2) any of the
measures could be applied to other PAC/LTC programs to align measures
across settings.
- Add measures that assess discharge to the community and the
quality of transition planning.
- Include Nursing Home-CAHPS measures in the program to address
patient experience.
Program Update: None
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:
- The VM is an adjustment made on a per claim basis to Medicare
payments for items and services furnished under the Medicare
Physician Fee Schedule, based on performance on cost and quality
measures during a performance period. The goal of the program
is to encourage and reward physicians for furnishing high-quality,
efficient, patient-centered clinical care.
- Alignment of federal programs – the VM is aligned with the
Physician Quality Reporting System (PQRS) and provides an additional
incentive to physicians and groups to report quality measures through
PQRS.
- The program also seeks to align measures, and consequently align
incentives to improve care, with the Hospital VBP Program in the
future, to the extent possible.
Critical Program Objectives:
- NQF-endorsed measures are strongly preferred for
pay-for-performance programs; measures that are not NQF-endorsed
should be submitted for endorsement or removed.
- Include measures that have been reported in a national program
for at least one year (e.g.,PQRS) and ideally can be linked with
particular cost or resource use measures to capture value.
- Focus on outcomes, composites, process measures that are proximal
to outcomes, appropriate care (e.g., overuse), and care coordination
measures (measures included in the MAP Families of Measures generally
reflect these characteristics).
- Monitor for unintended consequences to vulnerable populations
(e.g., through stratification).
Program Update:
- In 2017, the Value Modifier applies to all physician solo
practitioners and physicians in groups of all sizes.
- In 2018, the Value Modifier applies to all physician and
non-physician eligible professionals.
- Quality tiering is the method by which quality and cost
performance that is substantially better than or worse than average
is recognized through payment adjustments. Quality tiering is
mandatory for all groups and solo practitioners subject to the 2017
Value Modifier but smaller groups of one to nine eligible
professionals can only earn upward or neutral (no) payment
adjustments under this methodology.
Index of Public Comments (by Measure and Program)
- 30
Day Unplanned Readmissions for Cancer Patients (Program: PPS-Exempt Cancer
Hospital Quality Reporting Program; MUC ID: X3629)
- Acute
Care Hospitalization (Claims-Based) (Program: Medicare Shared Savings
Program; MUC ID: E0171)
- ACUTE
MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (Program: Medicare Shared
Savings Program; MUC ID: X3766)
- ACUTE
MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3766)
- ADHD:
Symptom Reduction in Follow-up Period (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3280)
- Administrative
Communication (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0291)
- Adult
Kidney Disease: Referral to Hospice (Program: Medicare Shared Savings
Program; MUC ID: X3732)
- Adult
Kidney Disease: Referral to Hospice (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3732)
- Advance
Care Plan (Program: Ambulatory Surgical Centers Quality Reporting Program;
MUC ID: E0326)
- Advance
Care Plan (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0326)
- Adverse
Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on
Warfarin (Program: Medicare Shared Savings Program; MUC ID:
X3485)
- Adverse
Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on
Warfarin (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3485)
- Adverse
Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on
Warfarin (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3485)
- Adverse
Drug Events: - Inappropriate Renal Dosing of Anticoagulants (Program:
Inpatient Quality Reporting Program; MUC ID: X3323)
- Adverse
Drug Events: - Inappropriate Renal Dosing of Anticoagulants (Program:
Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access
Hospitals (CAHs); MUC ID: X3323)
- Alcohol
Screening and Brief Intervention (ASBI) in the ER (Program: Medicare
Shared Savings Program; MUC ID: X3445)
- Alcohol
Screening and Brief Intervention (ASBI) in the ER (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID:
X3445)
- Alcohol
Screening and Brief Intervention (ASBI) in the ER (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3445)
- Amblyopia
Screening in Children (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X3817)
- Amblyopia
Screening in Children (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3817)
- Ambulatory
surgery patients with appropriate method of hair removal (Program:
Ambulatory Surgical Centers Quality Reporting Program; MUC ID:
E0515)
- Anesthesiology
Smoking Abstinence (Program: Medicare Shared Savings Program; MUC ID:
X3811)
- Anesthesiology
Smoking Abstinence (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3811)
- Annual
Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug
Users (Program: Medicare Shared Savings Program; MUC ID:
X3513)
- Annual
Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug
Users (Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3513)
- Antipsychotic
Use in Persons with Dementia (Program: Medicare Shared Savings Program;
MUC ID: E2111)
- Appropriate
age for colorectal cancer screening (Program: Medicare Shared Savings
Program; MUC ID: X3758)
- Appropriate
age for colorectal cancer screening (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3758)
- Appropriate
follow-up imaging for incidental abdominal lesions (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3759)
- Appropriate
follow-up imaging for incidental thyroid nodules in patients (Program:
Medicare Shared Savings Program; MUC ID: X3763)
- Appropriate
follow-up imaging for non-traumatic knee pain (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3802)
- Appropriate
use of imaging for non-traumatic shoulder pain (Program: Medicare Shared
Savings Program; MUC ID: X3803)
- Appropriate
use of imaging for non-traumatic shoulder pain (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3803)
- Assessment
for Psoriatic Arthritis (Program: Medicare Shared Savings Program; MUC ID:
X3274)
- Assessment
for Psoriatic Arthritis (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: X3274)
- Assessment
Of Medication Overuse In The Treatment Of Primary Headache Disorders
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3783)
- At
least 12 regional lymph nodes are removed and pathologically examined for
resected colon cancer (Program: PPS-Exempt Cancer Hospital Quality
Reporting Program; MUC ID: E0225)
- Blood
Pressure Screening by age 18 (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: E1553)
- Breast
Cancer Screening (Program: Medicare Shared Savings Program; MUC ID:
X3797)
- Breast
Cancer Screening (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3797)
- Cardiac
Rehabilitation Patient Referral From an Inpatient Setting (Program:
Inpatient Quality Reporting Program; MUC ID: E0642)
- Cellulitis
Clinical Episode-Based Payment Measure (Program: Physician Feedback; MUC
ID: X0354)
- Cellulitis
Clinical Episode-Based Payment Measure (Program: Inpatient Quality
Reporting Program; MUC ID: X0354)
- Cellulitis
Clinical Episode-Based Payment Measure (Program: Value-Based Payment
Modifier; MUC ID: X0354)
- Chronic
Opioid Therapy Follow-up Evaluation (Program: Medicare Shared Savings
Program; MUC ID: X3775)
- Chronic
Opioid Therapy Follow-up Evaluation (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3775)
- Clinical
Outcome post Endovascular Stroke Treatment (Program: Medicare Shared
Savings Program; MUC ID: X3756)
- Clinical
Outcome post Endovascular Stroke Treatment (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3756)
- Clinical
Response to Oral Systemic or Biologic Medications (Program: Medicare
Shared Savings Program; MUC ID: X3726)
- Clinical
Response to Oral Systemic or Biologic Medications (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3726)
- Closing
the Referral Loop - Critical Information Communicated with Request for
Referral (Program: Medicare Shared Savings Program; MUC ID:
X3283)
- Closing
the Referral Loop - Critical Information Communicated with Request for
Referral (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3283)
- Closing
the Referral Loop - Critical Information Communicated with Request for
Referral (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3283)
- Closing
the Referral Loop - Specialist Report Sent to Primary Care Physician
(Program: Medicare Shared Savings Program; MUC ID: X3302)
- Coagulation
studies in adult patients presenting with chest pain with no coagulopathy or
bleeding (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3780)
- Cognitive
Impairment Assessment Among At-Risk Older Adults (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID:
X3469)
- Cognitive
Impairment Assessment Among At-Risk Older Adults (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3469)
- Communication
and shared decision-making with patients and families for interventional
oncology procedures (Program: Medicare Shared Savings Program; MUC ID:
X3735)
- Complete
assessment and evaluation of patientís pelvic organ prolapse prior to surgical
repair (Program: Medicare Shared Savings Program; MUC ID:
X3751)
- Complete
assessment and evaluation of patientís pelvic organ prolapse prior to surgical
repair (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3751)
- Compliance
with Ventilator Process Elements during LTCH stay (Program: Long-Term Care
Hospitals Quality Reporting Program; MUC ID: X3705)
- Comprehensive
Diabetes Care: Eye Exam (Program: Medicare Shared Savings Program; MUC ID:
E0055)
- Consideration
of Non-Pharmacologic Interventions (Program: Medicare Shared Savings
Program; MUC ID: X3776)
- Consideration
of Non-Pharmacologic Interventions (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3776)
- Controlling
High Blood Pressure (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3792)
- Coordinating
Care - Emergency Department Referrals (Program: Medicare Shared Savings
Program; MUC ID: X3466)
- Coordinating
Care - Emergency Department Referrals (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3466)
- Coordinating
Care - Emergency Department Referrals (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3466)
- Coordinating
Care - Follow-Up with Eligible Provider (Program: Medicare Shared Savings
Program; MUC ID: X3465)
- Coordinating
Care - Follow-Up with Eligible Provider (Program: Medicare and Medicaid
EHR Incentive Programs for Eligible Professionals; MUC ID: X3465)
- Coordinating
Care - Follow-Up with Eligible Provider (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3465)
- Coronary
Artery Disease (CAD): Beta-Blocker Therapy ñ Prior Myocardial Infarction (MI)
or Left Ventricular Systolic Dysfunction (LVEF < 40%) (Program:
Medicare Shared Savings Program; MUC ID: E0070)
- Cultural
Competency Implementation Measure (Program: End-Stage Renal Disease
Quality Incentive Program; MUC ID: E1919)
- Cultural
Competency Reporting Measure (Program: End-Stage Renal Disease Quality
Incentive Program; MUC ID: X3716)
- Death
among surgical inpatients with serious, treatable complications (PSI 4)
(Program: Hospital Value-Based Purchasing Program; MUC ID: E0351)
- Delivered
Dose in Peritoneal Dialysis Above Minimum (Program: End-Stage Renal
Disease Quality Incentive Program; MUC ID: X3718)
- Delivered
Dose of Dialysis Above Minimum - Composite Score (Program: End-Stage Renal
Disease Quality Incentive Program; MUC ID: X2051)
- Delivered
Dose of Hemodialysis Above Minimum (Program: End-Stage Renal Disease
Quality Incentive Program; MUC ID: X3717)
- Depression
Remission at Six Months (Program: Medicare Shared Savings Program; MUC ID:
E0711)
- Diabetes:
Foot exam (Program: Medicare Shared Savings Program; MUC ID:
E0056)
- Diabetes:
Hemoglobin A1c Overtreatment in the Elderly (Program: Medicare Shared
Savings Program; MUC ID: X3476)
- Diabetes:
Hemoglobin A1c Overtreatment in the Elderly (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID:
X3476)
- Diabetes:
Hemoglobin A1c Overtreatment in the Elderly (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3476)
- Documentation
of a Health Care Proxy for Patients with Cognitive Impairment (Program:
Medicare and Medicaid EHR Incentive Programs for Eligible Professionals; MUC
ID: X3468)
- Documentation
of a Health Care Proxy for Patients with Cognitive Impairment (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3468)
- Documentation
of Current Medications in the Medical Record (Program: End-Stage Renal
Disease Quality Incentive Program; MUC ID: E0419)
- Documentation
of Current Medications in the Medical Record (Program: Medicare Shared
Savings Program; MUC ID: E0419)
- Documentation
of Signed Opioid Treatment Agreement (Program: Medicare Shared Savings
Program; MUC ID: X3777)
- Documentation
of Signed Opioid Treatment Agreement (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3777)
- Door
to puncture time for endovascular stroke treatment (Program: Medicare
Shared Savings Program; MUC ID: X3747)
- Door
to puncture time for endovascular stroke treatment (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3747)
- Evaluation
or Interview for Risk of Opioid Misuse (Program: Medicare Shared Savings
Program; MUC ID: X3774)
- Evaluation
or Interview for Risk of Opioid Misuse (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3774)
- External
Beam Radiotherapy for Bone Metastases (Program: Hospital Outpatient
Quality Reporting Program; MUC ID: E1822)
- Extravasation
of contrast following contrast-enhanced computed tomography (CT) (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3523)
- Falls
with injury (Program: Inpatient Quality Reporting Program; MUC ID:
E0202)
- Frequency
of inadequate bowel preparation (Program: Medicare Shared Savings Program;
MUC ID: X3760)
- Frequency
of inadequate bowel preparation (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3760)
- Functional
Status Assessment and Goal Achievement for Patients with Congestive Heart
Failure (Program: Medicare Shared Savings Program; MUC ID:
X3481)
- Functional
Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
(Program: Medicare Shared Savings Program; MUC ID: X3053)
- Functional
Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3053)
- Functional
Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3053)
- Functional
Status Outcomes for Patients Receiving Primary Total Hip Replacements
(Program: Medicare Shared Savings Program; MUC ID: X3483)
- Functional
Status Outcomes for Patients Receiving Primary Total Hip Replacements
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3483)
- Functional
Status Outcomes for Patients Receiving Primary Total Hip Replacements
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3483)
- Functional
Status Outcomes for Patients Receiving Primary Total Knee Replacements
(Program: Medicare Shared Savings Program; MUC ID: X3482)
- Functional
Status Outcomes for Patients Receiving Primary Total Knee Replacements
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3482)
- Functional
Status Outcomes for Patients Receiving Primary Total Knee Replacements
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3482)
- Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure (Program: Physician
Feedback; MUC ID: X0355)
- Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure (Program: Inpatient
Quality Reporting Program; MUC ID: X0355)
- Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure (Program: Value-Based
Payment Modifier; MUC ID: X0355)
- Gout:
Serum Urate Monitoring (Program: Medicare Shared Savings Program; MUC ID:
S2521)
- Gout:
Serum Urate Monitoring (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: S2521)
- Gout:
Serum Urate Monitoring (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: S2521)
- Gout:
Urate Lowering Therapy (Program: Medicare Shared Savings Program; MUC ID:
S2550)
- Gout:
Urate Lowering Therapy (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: S2550)
- Gout:
Urate Lowering Therapy (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: S2550)
- Health
literacy measure derived from the health literacy domain of the C-CAT
(Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E1898)
- Hepatitis
C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C
Virus (HCV) Infection (Program: Medicare Shared Savings Program; MUC ID:
X3816)
- Hepatitis
C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C
Virus (HCV) Infection (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X3816)
- Hepatitis
C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C
Virus (HCV) Infection (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3816)
- Hepatitis
C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
(Program: Medicare Shared Savings Program; MUC ID: X3512)
- Hepatitis
C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3512)
- Hepatitis
C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3512)
- Hip
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Physician Feedback; MUC ID: X0356)
- Hip
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Hospital Value-Based Purchasing Program; MUC ID: X0356)
- Hip
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Inpatient Quality Reporting Program; MUC ID: X0356)
- Hip
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Value-Based Payment Modifier; MUC ID: X0356)
- HIV
medical visit frequency (Program: Medicare Shared Savings Program; MUC ID:
E2079)
- HIV
Screening of STI patients (Program: Medicare Shared Savings Program; MUC
ID: X3300)
- HIV
Screening of STI patients (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X3300)
- HIV
Screening of STI patients (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: X3300)
- HIV
Viral Load Suppression (Program: Medicare Shared Savings Program; MUC ID:
E2082)
- HIV:
Ever screened for HIV (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X3299)
- HIV:
Ever screened for HIV (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3299)
- Hospice
and Palliative Care ñ Treatment Preferences (Program: PPS-Exempt Cancer
Hospital Quality Reporting Program; MUC ID: E1641)
- Hospital
30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) following Chronic
Obstructive Pulmonary Disease (COPD) Hospitalization (Program: Hospital
Value-Based Purchasing Program; MUC ID: E1893)
- Hospital
30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia
hospitalization (Program: Hospital Value-Based Purchasing Program; MUC ID:
E0468)
- Hospital
30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia
hospitalization (Program: Inpatient Quality Reporting Program; MUC ID:
E0468)
- Hospital
30-day, all-cause, risk-standardized readmission rate (RSRR) following
pneumonia hospitalization (Program: Hospital Readmission Reduction
Program; MUC ID: E0506)
- Hospital
30-day, all-cause, risk-standardized readmission rate (RSRR) following
pneumonia hospitalization (Program: Inpatient Quality Reporting Program;
MUC ID: E0506)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care following
acute myocardial infarction (AMI) hospitalization (Program: Inpatient
Quality Reporting Program; MUC ID: X3728)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care following
heart failure hospitalization (Program: Inpatient Quality Reporting
Program; MUC ID: X3722)
- Hospital
30-day, all-cause, unplanned risk-standardized days in acute care following
pneumonia hospitalization (Program: Inpatient Quality Reporting Program;
MUC ID: X3727)
- Hospital-level,
risk-standardized payment associated with an episode of care for primary
elective total hip and/or total knee arthroplasty (THA/TKA) (Program:
Inpatient Quality Reporting Program; MUC ID: X3620)
- Hospital-Wide
All-Cause Unplanned Readmission Hybrid eMeasure (Program: Inpatient
Quality Reporting Program; MUC ID: X3701)
- Hospital-Wide
All-Cause Unplanned Readmission Hybrid eMeasure (Program: Medicare and
Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals
(CAHs); MUC ID: X3701)
- Imaging
in adult ED patients with minor head injury (Program: Medicare Shared
Savings Program; MUC ID: X3764)
- Imaging
in adult ED patients with minor head injury (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3764)
- Imaging
in pediatric ED patients aged 2 through 17 years with minor head injury
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3778)
- Influenza
Immunization (Program: PPS-Exempt Cancer Hospital Quality Reporting
Program; MUC ID: E1659)
- Influenza
vaccination coverage among healthcare personnel (HCP) (Program: PPS-Exempt
Cancer Hospital Quality Reporting Program; MUC ID: E0431)
- In-hospital
mortality following elective open repair of AAAs (Program: Medicare Shared
Savings Program; MUC ID: E1523)
- In-hospital
mortality following elective open repair of AAAs (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: E1523)
- INR
Monitoring for Individuals on Warfarin (e-specified version of NQF #0555)
(Program: Medicare Shared Savings Program; MUC ID: E0555)
- INR
Monitoring for Individuals on Warfarin (e-specified version of NQF #0555)
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: E0555)
- INR
Monitoring for Individuals on Warfarin (e-specified version of NQF #0555)
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: E0555)
- Intimate
Partner (Domestic) Violence Screening (Program: Medicare Shared Savings
Program; MUC ID: X3446)
- Intimate
Partner (Domestic) Violence Screening (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3446)
- Intimate
Partner (Domestic) Violence Screening (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3446)
- IRF
Functional Outcome Measure: Change in Mobility Score for Medical
Rehabilitation Patients (Program: Inpatient Rehabilitation Facilities
Quality Reporting Program; MUC ID: S2634)
- IRF
Functional Outcome Measure: Change in Self-Care Score for Medical
Rehabilitation Patients (Program: Inpatient Rehabilitation Facilities
Quality Reporting Program; MUC ID: S2633)
- IRF
Functional Outcome Measure: Discharge Mobility Score for Medical
Rehabilitation Patients (Program: Inpatient Rehabilitation Facilities
Quality Reporting Program; MUC ID: S2636)
- IRF
Functional Outcome Measure: Discharge Self-Care Score for Medical
Rehabilitation Patients (Program: Inpatient Rehabilitation Facilities
Quality Reporting Program; MUC ID: S2635)
- Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure (Program: Physician
Feedback; MUC ID: X0351)
- Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure (Program: Hospital
Value-Based Purchasing Program; MUC ID: X0351)
- Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure (Program: Inpatient
Quality Reporting Program; MUC ID: X0351)
- Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure (Program:
Value-Based Payment Modifier; MUC ID: X0351)
- Knee
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Physician Feedback; MUC ID: X0352)
- Knee
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Hospital Value-Based Purchasing Program; MUC ID: X0352)
- Knee
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Inpatient Quality Reporting Program; MUC ID: X0352)
- Knee
Replacement/ Revision Clinical Episode-Based Payment Measure (Program:
Value-Based Payment Modifier; MUC ID: X0352)
- MD
Multidisciplinary Care Plan Developed or Updated (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3791)
- Medication
Information (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0293)
- MEDICATION
PRESCRIBED FOR ACUTE MIGRAINE ATTACK (Program: Medicare Shared Savings
Program; MUC ID: X3771)
- MEDICATION
PRESCRIBED FOR ACUTE MIGRAINE ATTACK (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3771)
- Medications
Documentation Reporting (Program: End-Stage Renal Disease Quality
Incentive Program; MUC ID: X3721)
- Migraine
Or Cervicogenic Headache Related Disability Functional Status (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3796)
- MRI
Lumbar Spine for Low Back Pain (Program: Medicare Shared Savings Program;
MUC ID: E0514)
- National
Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection
(CAUTI) Outcome (Program: Hospital-Acquired Condition (HAC) Reduction
Program; MUC ID: S0138)
- National
Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection
(CAUTI) Outcome (Program: Hospital Value-Based Purchasing Program; MUC ID:
S0138)
- National
Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection
(CAUTI) Outcome (Program: Inpatient Quality Reporting Program; MUC ID:
S0138)
- National
Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection
(CAUTI) Outcome (Program: Medicare Shared Savings Program; MUC ID:
S0138)
- National
Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection
(CLABSI) Outcome (Program: Hospital-Acquired Condition (HAC) Reduction
Program; MUC ID: S0139)
- National
Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection
(CLABSI) Outcome (Program: Hospital Value-Based Purchasing Program; MUC
ID: S0139)
- National
Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection
(CLABSI) Outcome (Program: Inpatient Quality Reporting Program; MUC ID:
S0139)
- National
Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset
Clostridium difficile Infection (CDI) Outcome Measure (Program: PPS-Exempt
Cancer Hospital Quality Reporting Program; MUC ID: E1717)
- National
Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset
Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome
Measure (Program: PPS-Exempt Cancer Hospital Quality Reporting Program;
MUC ID: E1716)
- Needle
biopsy to establish diagnosis of cancer precedes surgical
excision/resection (Program: PPS-Exempt Cancer Hospital Quality Reporting
Program; MUC ID: E0221)
- Normothermia
Outcome (Program: Ambulatory Surgical Centers Quality Reporting Program;
MUC ID: X3719)
- Nursing
Hours per Patient Day (Program: Inpatient Quality Reporting Program; MUC
ID: E0205)
- Nursing
Information (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0296)
- Nutritional
Status or Growth Trajectories Monitored (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3801)
- O/ASPECS
About Facility and Staff (Program: Ambulatory Surgical Centers Quality
Reporting Program; MUC ID: X3698)
- O/ASPECS
About Facility and Staff (Program: Hospital Outpatient Quality Reporting
Program; MUC ID: X3698)
- O/ASPECS
Communication (Program: Ambulatory Surgical Centers Quality Reporting
Program; MUC ID: X3699)
- O/ASPECS
Communication (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: X3699)
- O/ASPECS
Discharge and Recovery (Program: Ambulatory Surgical Centers Quality
Reporting Program; MUC ID: X3697)
- O/ASPECS
Discharge and Recovery (Program: Hospital Outpatient Quality Reporting
Program; MUC ID: X3697)
- O/ASPECS
Overall Facility Rating (Program: Ambulatory Surgical Centers Quality
Reporting Program; MUC ID: X3702)
- O/ASPECS
Overall Facility Rating (Program: Hospital Outpatient Quality Reporting
Program; MUC ID: X3702)
- O/ASPECS
Recommend (Program: Ambulatory Surgical Centers Quality Reporting Program;
MUC ID: X3703)
- O/ASPECS
Recommend (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
X3703)
- Optimal
Asthma Care 2014 (Program: Medicare Shared Savings Program; MUC ID:
X3773)
- Optimal
Asthma Care 2014 (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3773)
- Optimal
Vascular Care (Program: Medicare Shared Savings Program; MUC ID:
E0076)
- Optimal
Vascular Care (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
E0076)
- Overuse
of Barbiturate Containing Medications for Primary Headache Disorders
(Program: Medicare Shared Savings Program; MUC ID: X3765)
- Overuse
of Barbiturate Containing Medications for Primary Headache Disorders
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3765)
- Overuse
Of Neuroimaging For Patients With Primary Headache And A Normal Neurological
Examination (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3785)
- Overuse
Of Opioid Containing Medications For Primary Headache Disorders (Program:
Medicare Shared Savings Program; MUC ID: X3770)
- Overuse
Of Opioid Containing Medications For Primary Headache Disorders (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3770)
- Participation
in a Patient Safety Culture Survey (Program: Inpatient Quality Reporting
Program; MUC ID: X3689)
- Patient
Counseled About Health Care Decision-Making (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3789)
- Patient
fall rate (Program: Inpatient Quality Reporting Program; MUC ID:
E0141)
- Patient
fall rate (Program: Inpatient Rehabilitation Facilities Quality Reporting
Program; MUC ID: E0141)
- Patient
fall rate (Program: Long-Term Care Hospitals Quality Reporting Program;
MUC ID: E0141)
- Patient
Information (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0294)
- Patient
Queried about Pain and Pain Interference with Function (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3800)
- Patients
with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3787)
- Payment-Standardized
Medicare Spending Per Beneficiary (MSPB) (Program: Medicare Shared Savings
Program; MUC ID: E2158)
- PC-02
Cesarean Section (Provider Level) (Program: Medicare Shared Savings
Program; MUC ID: X3788)
- PC-02
Cesarean Section (Provider Level) (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3788)
- Pediatric
Kidney Disease: Discussion of Care Planning (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3733)
- Percent
of Patients with Pressure Ulcers That Are New or Worsened (Program: Home
Health Quality Reporting Program; MUC ID: X3704)
- Percentage
of patients treated for varicose veins who are treated with saphenous ablation
and receive an outcomes survey before and after treatment (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3739)
- Percentage
of patients with a retrievable inferior vena cava filter who are appropriately
assessed for continued filtration or device removal (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3755)
- Performing
an intraoperative rectal examination at the time of prolapse repair
(Program: Medicare Shared Savings Program; MUC ID: X3740)
- Performing
an intraoperative rectal examination at the time of prolapse repair
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3740)
- Performing
cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect
lower urinary tract injury (Program: Medicare Shared Savings Program; MUC
ID: X3752)
- Performing
cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect
lower urinary tract injury (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: X3752)
- Perinatal
Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in
vertex position delivered by cesarean section (Program: Inpatient Quality
Reporting Program; MUC ID: X1970)
- Perinatal
Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in
vertex position delivered by cesarean section (Program: Medicare and
Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals
(CAHs); MUC ID: X1970)
- Perioperative
Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy
(Program: Medicare Shared Savings Program; MUC ID: E0465)
- Perioperative
Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: E0465)
- Perioperative
Temperature Management (Program: Medicare Shared Savings Program; MUC ID:
X3809)
- Perioperative
Temperature Management (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: X3809)
- Photodocumentation
of cecal intubation (Program: Medicare Shared Savings Program; MUC ID:
X3761)
- Photodocumentation
of cecal intubation (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3761)
- Physician
Information (Program: Hospital Outpatient Quality Reporting Program; MUC
ID: E0295)
- Plan
Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3794)
- Plan
Of Care Or Referral For Possible Medication Overuse Headache (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3784)
- Post
breast conservation surgery irradiation (Program: PPS-Exempt Cancer
Hospital Quality Reporting Program; MUC ID: E0219)
- Post-Anesthetic
Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit
(PACU) (Program: Medicare Shared Savings Program; MUC ID:
X3810)
- Post-Anesthetic
Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit
(PACU) (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3810)
- Post-Anesthetic
Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care
from Procedure Room to Intensive Care Unit (ICU) (Program: Medicare Shared
Savings Program; 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) (Program: Physician
Quality Reporting System (PQRS); Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3807)
- Preoperative
assessment of occult stress urinary incontinence prior to any pelvic organ
prolapse repair (Program: Medicare Shared Savings Program; MUC ID:
X3746)
- Preoperative
assessment of occult stress urinary incontinence prior to any pelvic organ
prolapse repair (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3746)
- Preoperative
assessment of sexual function prior to any pelvic organ prolapse repair
(Program: Medicare Shared Savings Program; MUC ID: X3742)
- Preoperative
assessment of sexual function prior to any pelvic organ prolapse repair
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3742)
- Preoperative
exclusion of uterine malignancy prior to any pelvic organ prolapse repair
(Program: Medicare Shared Savings Program; MUC ID: X3741)
- Preoperative
exclusion of uterine malignancy prior to any pelvic organ prolapse repair
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3741)
- Preoperative
pessary for pelvic organ prolapse attempted (Program: Medicare Shared
Savings Program; MUC ID: X3745)
- Preoperative
pessary for pelvic organ prolapse attempted (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3745)
- Preoperative
pessary for pelvic organ prolapse offered (Program: Medicare Shared
Savings Program; MUC ID: X3750)
- Preoperative
pessary for pelvic organ prolapse offered (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3750)
- Preoperative
Use of Aspirin for Patients with Drug-Eluting Coronary Stents (Program:
Medicare Shared Savings Program; MUC ID: X3808)
- Preoperative
Use of Aspirin for Patients with Drug-Eluting Coronary Stents (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3808)
- Prescription
of HIV Antiretroviral Therapy (Program: Medicare Shared Savings Program;
MUC ID: E2083)
- Prevention
of Post-Operative Nausea and Vomiting (PONV) ñ Combination (Program:
Medicare Shared Savings Program; MUC ID: X3806)
- Prevention
of Post-Operative Nausea and Vomiting (PONV) ñ Combination (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3806)
- Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief
Counseling (Program: Medicare Shared Savings Program; MUC ID:
E2152)
- Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief
Counseling (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: E2152)
- Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief
Counseling (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
E2152)
- Preventive
Migraine Medication Prescribed (Program: Medicare Shared Savings Program;
MUC ID: X3772)
- Preventive
Migraine Medication Prescribed (Program: Physician Quality Reporting
System (PQRS); Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3772)
- Primary
C-Section Rate 2014 (Program: Medicare Shared Savings Program; MUC ID:
X3768)
- Primary
C-Section Rate 2014 (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3768)
- Procedures
and Tests (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0297)
- Proportion
of Patients Hospitalized with AMI that have a Potentially Avoidable
Complication (during the Index Stay or in the 30-day Post-Discharge
Period) (Program: Inpatient Quality Reporting Program; MUC ID:
E0704)
- Proportion
of Patients Hospitalized with Pneumonia that have a Potentially Avoidable
Complication (during the Index Stay or in the 30-day Post-Discharge
Period) (Program: Inpatient Quality Reporting Program; MUC ID:
E0708)
- Proportion
of Patients Hospitalized with Stroke that have a Potentially Avoidable
Complication (during the Index Stay or in the 30-day Post-Discharge
Period) (Program: Inpatient Quality Reporting Program; MUC ID:
E0705)
- Proportion
of patients sustaining a bladder injury at the time of any pelvic organ
prolapse repair (Program: Medicare Shared Savings Program; MUC ID:
X3743)
- Proportion
of patients sustaining a bladder injury at the time of any pelvic organ
prolapse repair (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3743)
- Proportion
of patients sustaining a major viscus injury at the time of any pelvic organ
prolapse repair (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3744)
- Proportion
of patients sustaining a ureter injury at the time of any pelvic organ
prolapse repair (Program: Medicare Shared Savings Program; MUC ID:
X3813)
- Proportion
of patients sustaining a ureter injury at the time of any pelvic organ
prolapse repair (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3813)
- Quality
Of Life Assessment For Patients With Primary Headache Disorders (Program:
Physician Quality Reporting System (PQRS); Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3786)
- Rate
of surgical conversion from lower extremity endovascular revascularization
procedure (Program: Physician Quality Reporting System (PQRS); Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3754)
- Risky
Behavior Assessment or Counseling by Age 13 Years (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID:
E1406)
- Risky
Behavior Assessment or Counseling by Age 18 Years (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID:
E1507)
- Scoliosis
Evaluation Ordered (Program: Physician Quality Reporting System (PQRS);
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID:
X3798)
- Skill
mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN],
unlicensed assistive personnel [UAP], and contract) (Program: Inpatient
Quality Reporting Program; MUC ID: E0204)
- Skilled
Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure
(Program: Medicare Shared Savings Program; MUC ID: S2510)
- Skilled
Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure
(Program: Skilled Nursing Facilities Value-Based Purchasing; MUC ID:
S2510)
- Spine
Fusion/ Refusion Clinical Episode-Based Payment Measure (Program:
Physician Feedback; MUC ID: X0353)
- Spine
Fusion/ Refusion Clinical Episode-Based Payment Measure (Program:
Inpatient Quality Reporting Program; MUC ID: X0353)
- Spine
Fusion/ Refusion Clinical Episode-Based Payment Measure (Program:
Value-Based Payment Modifier; MUC ID: X0353)
- Statin
Therapy for the Prevention and Treatment of Cardiovascular Disease
(Program: Medicare Shared Savings Program; MUC ID: X3729)
- Statin
Therapy for the Prevention and Treatment of Cardiovascular Disease
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3729)
- Statin
Therapy for the Prevention and Treatment of Cardiovascular Disease
(Program: Physician Quality Reporting System (PQRS); Physician Compare;
Physician Feedback; Value-Based Payment Modifier; MUC ID: X3729)
- SUB-2
Alcohol Use Brief Intervention Provided or Offered. SUB-2a Alcohol Use Brief
Intervention Received. (Program: Inpatient Psychiatric Facilities Quality
Reporting Program; MUC ID: E1663)
- 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 (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X4007)
- 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 (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: X4208)
- Substance
Use Screening and Intervention Composite (Program: Medicare Shared Savings
Program; MUC ID: X3475)
- Substance
Use Screening and Intervention Composite (Program: Medicare and Medicaid
EHR Incentive Programs for Eligible Professionals; MUC ID: X3475)
- Substance
Use Screening and Intervention Composite (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3475)
- Timely
Evaluation of High-Risk Individuals in the Emergency Department (Program:
Inpatient Quality Reporting Program; MUC ID: X1234)
- Timely
Evaluation of High-Risk Individuals in the Emergency Department (Program:
Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access
Hospitals (CAHs); MUC ID: X1234)
- Timely
Transmission of Transition Record (Discharges from an Inpatient Facility to
Home/Self Care or Any Other Site of Care) (Program: Inpatient Psychiatric
Facilities Quality Reporting Program; MUC ID: E0648)
- TOB-3
Tobacco Use Treatment Provided or Offered at Discharge AND TOB-3a Tobacco Use
Treatment at Discharge (Program: Inpatient Psychiatric Facilities Quality
Reporting Program; MUC ID: E1656)
- TOTAL
PER CAPITA COST MEASURE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES
(Program: Medicare Shared Savings Program; MUC ID: X2147)
- Transition
Record with Specified Elements Received by Discharged Patients (Discharges
from an Inpatient Facility to Home/Self Care or Any Other Site of Care)
(Program: Inpatient Psychiatric Facilities Quality Reporting Program; MUC ID:
E0647)
- Unnecessary
Screening Colonoscopy in Older Adults (Program: Medicare Shared Savings
Program; MUC ID: X3769)
- Unnecessary
Screening Colonoscopy in Older Adults (Program: Physician Quality
Reporting System (PQRS); Physician Compare; Physician Feedback; Value-Based
Payment Modifier; MUC ID: X3769)
- Unplanned
Anterior Vitrectomy (Program: Ambulatory Surgical Centers Quality
Reporting Program; MUC ID: X3720)
- Use
of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic
Headache (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
X607)
- Use
of Imaging Studies for Low Back Pain (Program: Medicare Shared Savings
Program; MUC ID: E0052)
- Use
of Multiple Concurrent Antipsychotics in Children and Adolescents
(Program: Medicare and Medicaid EHR Incentive Programs for Eligible
Professionals; MUC ID: X3472)
- Use
of premedication before contrast-enhanced imaging studies in patients with
documented contrast allergy (Program: Physician Quality Reporting System
(PQRS); Physician Compare; Physician Feedback; Value-Based Payment Modifier;
MUC ID: X3781)
- Venous
Thromboembolism Prophylaxis (Program: Inpatient Rehabilitation Facilities
Quality Reporting Program; MUC ID: E0371)
- Venous
Thromboembolism Prophylaxis (Program: Long-Term Care Hospitals Quality
Reporting Program; MUC ID: E0371)
- Ventilator
Weaning (Liberation) Rate (Program: Long-Term Care Hospitals Quality
Reporting Program; MUC ID: X3706)
- Vital
Signs (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0292)
Full Comments (Listed by Measure)
| (Program: Skilled Nursing Facilities Value-Based
Purchasing; Ambulatory Surgical Centers Quality Reporting Program ; MUC
ID: A general comment) |
- The American Association on Health and Disability (AAHD) (www.aahd.us) is
a national non-profit organization of public health professionals, both
practitioners and academics, with a primary concern for persons with
disabilities. The AAHD mission is to advance health promotion and wellness
initiatives for persons with disabilities. AAHD is an active member of the
Consortium for Citizens with Disabilities (CCD) task force on long-term
services and supports (LTSS). AAHD represents the CCD task force on the NQF
workgroup on persons dually eligible for Medicare and Medicaid. AAHD
particularly appreciates NQF recognition of the need for measures in the
following areas: Discharge planning and communication: pages 17, 42, 44, 46,
63, 64, 97 ìCareî planning: pages 19, 73 Consumer experience: pages 18, 19, 72
Health literacy: page 46 Mobility functioning: pages 48, 49 Self care
functioning: page 49 Cognitive impairments: page 64 Children: page 68 Consumer
counseling: page 71 Quality of life: page 74 Communication and shared
decision-making: page 91 Falls prevention: pages 33, 42 Use of medication:
pages 45, 67, 75, 94 Mental health screening and treatment: pages 69, 93
Substance use disorder screening and treatment: pages 47, 52, 54, 56, 76, 78,
79 We encourage NQF to adopt these measures and further encourage CMS to use
them. Collective and comprehensive implementation should improve the lives of
persons with disabilities and enhance health plan and provider accountability
for improving the lives of persons with disabilities. Thank you for
considering our views. Sincerely, E. Clarke Ross, D.P.A. Public Policy
Director American Association on Health and Disability (Submitted by: American
Association on Health and Disability)
- Overview of ADCC Comments The ADCC Supports the MAPís Goal of Improving
Care Across Settings and Believes it would be Best Served by Ensuring that
Measures are Meaningful and Actionable to the Providers Who Use Them; This May
Require Modifying or Excluding Certain Proposed Measures The ADCC supports the
intent of the nine proposed measures under consideration for our program (see
Tables 1 and 2 and Appendix A). We believe these proposed measures target key
areas in care delivery and have the potential to improve outcomes. However,
to achieve this purpose, several require modification or clearer definitions
(see Table 1 and 2 and Appendix A). Some measures are already collected by
the Cancer Centers, and we have consistently demonstrated high performance on
these measures. Therefore, adoption of these measures offers little or no
benefit to our patients while increasing the reporting burden for the Cancer
Centers under the PCHQR. Other measures were developed in another care
setting and require revisions or additional stratifications to be meaningful
and actionable for the Cancer Centers. The ADCC Encourages Further Adoption
of Cancer-Specific Outcomes Measures in the Future As noted in previous
comment letters, a stronger emphasis on cancer-specific outcome measures would
be more valuable to our efforts to improve the quality and value of patient
care at our institutions. The ADCC Looks Forward to Contributing to the
Measure Development Process In December 2014, X3629: 30-Day Unplanned
Readmissions for Cancer Patients, stewarded by Seattle Cancer Care Alliance,
was conditionally supported by the National Quality Forum (NQF) MAP for
inclusion in the PCHQR. This measure has completed final testing and
validation, and the formal report will be available in February 2015. As
required under the terms of the MAP conditional support, the ADCC is also
working with the NQF to achieve formal measure endorsement. The ADCC
Appreciates the Application of Appropriate Sampling Methodologies to Our
Measures The ADCC continues to support adoption of an appropriate sampling
methodology for measures that will require manual chart abstraction. Many of
the currently proposed measures incorporate electronic data elements or are
part of a benchmarking or surveillance program in which the Cancer Centers
already participate. However, our review of E1641-Hospice and Palliative
Care-Treatment Preferences and E1659-Influenza Vaccination, in particular,
suggests that we would need to work outside of our existing processes to
obtain some of the required data elementsóa process that frequently requires
manual chart review. Should these measures be adopted for the PCHQR, we look
forward to working with the Centers for Medicare&Medicaid Services (CMS)
to develop an appropriate sampling methodology for our program. The ADCC
Requests that Federal Reporting Programs do not Adopt Duplicative Measures for
our Cancer Centers, which would Create Undue Administrative Burden In
addition, the redundancy of certain measures would add undue burden to data
collection, while offering questionable benefit for our patients. We note
that there is some overlap in the patient populations for E1716-National
Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset
Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure
and 0139-National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome Measure, which is already adopted for
the PCHQR. We strongly oppose the adoption of duplicative measures without
clear benefit for patients. Again, we thank you for your thoughtful
consideration of the proposed measures and for the opportunity to provide
input into the 2014-2015 Preliminary Recommendations. (Submitted by: Alliance
of Dedicated Cancer Centers)
- We noticed that there are only 2 pediatric areas for proposed measures:
one on TBI and the other on renal disease. As 1 in 5 children have special
health care needs, we would expect more pediatric measures proposed.(Submitted
by: Family Voices NJ)
- Adventist Health System (AHS), on behalf of our flagship organization
Florida Hospital, welcomes the opportunity to comment on the Measures
Application Partnership (MAP) 2015 Considerations for Implementing Measures in
Federal Programs Draft Report. We commend the National Quality Forum (NQF) for
its commitment to drive health care quality improvement and identify high
value health care quality measures. While we recognize that the short
timeframe given to respond to the MAP 2015 Draft Report is not the fault of
the NQF, AHS objects to the insufficient amount of time provided to consider
this and other issues from the NQF. More time must be allocated if there is a
true desire to receive the best thinking of the health care sector on these
matters. This needs to be facilitated via statutory changes that provide
additional time for review or through better coordination between the Centers
for Medicare & Medicaid Services (CMS) and NQF. The items advanced by NQF
are of great consequence to both consumers and providers. Yet the current
process does not allow for a well-considered contemplation and discussion. In
particular, we do not believe that the comment period for this report and list
of measure-specific recommendations was adequate. The depth and importance of
MAPís work calls for a longer comment period. We think that more time will
enable a more informed and productive discussion of these measures. AHS has
the following high-level comments on the MAP 2015 Draft Report. Due to time
constraints, we have decided to submit overarching comments rather than
comment on specific measure recommendations. We are very supportive of the
philosophical shift to ìMeasures that Matter.î We hope this translates to a
practical shift. We agree with MAPís exhortation that there is a need for a
counterbalance to the continuing proliferation of measures. We believe the
process of developing, endorsing and selecting quality measures for use in
federal programs must include an articulation and an agreement of what does
matter to the patient and to the payer. This can be put into a hierarchy that
ranges from essential (ìDid the provider do no harm?î) to peripheral (ìWas the
provider courteous and friendly?î). Once this is achieved, then measures can
be developed to assess what matters and provide information that is most
meaningful to patients. To further the achievement of this goal, there must be
a more vigorous application of statistical testing. AHS believes that the
current NQF standards fall short of what can be considered good science. We do
not think that accepting measures that have correlation coefficients of 0.4 is
a sufficient level of scientific rigor. Neither is accepting measures on
ìface-validityî alone. Related to moving to a more rigorous use of
statistics is the need to adjust the standards by patient Socioñdemographic
Status (SDS) variables. Comparing what is being achieved by a suburban
hospital that serves an affluent and well-educated community to an urban
hospital that serves an economically disadvantaged community is not
reasonable. While some argue that adjusting for SDS factors will hide
disparities, the reality is it will not. In actuality, the absence of SDS risk
adjustment likely masks disparities and enables some measures to be ìgamed.î
Hospitals that serve similar populations can and should be compared. This will
allow for focused comparisons and will begin to highlight disparities. There
is a great need for the alignment of quality measures. Hospitals and other
providers should not have to gather the same data over and over to report
essentially the same information to different agencies and programs. This is
not cost effective and often places an undue burden on clinicians. We support
MAPís stated preference for a parsimonious set of measures that target the
core objectives of federal quality programs. However, we are troubled that the
same measure can lead to multiple separate penalties for the failure to meet a
single standard. We disagree with MAPís assessment that this duplication is
useful. Providers should not be rewarded twice for meeting a standard. They
also should not be punished twice. For this reason, AHS strongly questions the
inherent fairness of use of duplication of some measures in the Hospital
Acquired Condition (HAC) Reduction Program and the Value-Based Purchasing
(VBP) Program. Different domains should use different measures. In this way a
more full orbed approach is being taken toward quality measurement and a basic
rule of fairness is observed. AHS is very supportive of moving to a harms
measure for quality. The first rule in medicine is ìFirst, do no harm.î Our
organization has focused on this over the last several years and achieved
excellent results. We are unsure about MAPís use of the term ìall cause harm
measure.î In the original taxonomy, harms measures consisted of two basic
categories: harms that did not reach the patient and harms that did reach the
patient. Under each of these categories, there are four levels of intensity of
harm. These range from ìthe event had the capacity to cause harmî to ìan error
occurred that may have contributed to, or resulted in, patient death.î The
range of these harms is significant and cannot be treated equally. AHS would
support a harms measure based upon the National Coordinating Council for
Medication Error Reporting and Prevention (NCC MERP) Index of Categorizing
Errors. AHS opposes the current all-cause condition-specific measures of
readmissions. The Affordable Care Act (ACA) called for measures of readmission
related to the original admission. While we agree that the hospital has to
reach out beyond its walls and extend its care into the community and home, we
believe that hospitals should only be held responsible for things that they
can control to a reasonable degree. Patient compliance, for instance, is
something that hospitals can influence but not necessarily control. It is not
unreasonable for the hospital to be expected to work with the patient and the
family to improve this factor. That a diabetic patient may be readmitted
because of lack of compliance does provide an incentive for the hospital to
institute better education in this area. However, it should not be counted
against the hospital if that patient slips on an icy sidewalk, falls, breaks a
bone and is readmitted because it is unrelated to the original admission. AHS
supports the inclusion of readmissions measures for Skilled-Nursing Facilities
(SNFs). We believe providers must have shared incentives and disincentives
that focus on achieving the most appropriate resource use for each individual
patient. It is our organizationís experience that a significant number of
readmissions come from SNFs. Most of these take place by 15th day post
discharge. Our analysis has found that the reasons for such early readmissions
from SNFs include guardian concerns that the patient is not getting the same
level of care that was provided in the hospital, the patient develops a fever
or the SNF consulting physician tells the nursing staff to send the patient to
the hospital emergency department rather than providing care directions. We do
not believe a hospital should be held to accountable for the actions or
decisions of a SNF. We appreciate the opportunity to comment on this report
and encourage MAP to seriously consider the concerns of the provider community
in their revisions. We support NQFís efforts to continually improve its
processes and are optimistic about the improvements in the process and
approach to measure analysis employed by the MAP. We look forward to the final
report and further improvements to the measurement of health care quality.
Sincerely, Richard E. Morrison Vice President, Government & Public Policy
Adventist Health System (Submitted by: Adventist Health System)
- Many of the measures require reassessments and therefore will generate
multiple encounters to calculate the measure (for example, x3053, Functional
Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
(encourage continued development)). CMS should test these measures for
reliability and validity given their complexity prior to implementation in any
pay-for-reporting or performance program. In addition, the measures do not
provide any guidance around the number needed to define performance and
therefore could have the unintended consequences of increased and potentially
unnecessary office visits. (Submitted by: American Medical
Association)
- While we appreciate the work of the committee, we are disappointed in the
lack of awareness of the current processes in IRFs. ARN recommends that the
LTC/PAC workgroup consist of members with additional insight and a greater
understanding into the specialty of rehabilitation. We also encourage NQF to
publish and respond to each comment (similar to CMS) versus summarizing so as
not to omit or skew what is being addressed/commented on.(Submitted by:
Association of Rehabilitation Nurses)
- January 13, 2015 The National Minority Quality Forum welcomes this
opportunity to provide comment to the National Quality Forum regarding the
recommendations from its Measure Applications Partnership on the 202
standardized performance measures under consideration for use in 20 federal
programs and issues that attend their implementation. The National Minority
Quality Forum is a Washington, DC-based not-for-profit, non-partisan,
independent research and advocacy organization founded in 1998 that is
dedicated to improving the quality of healthcare that is available for and
provided to all populations. The Forum informs public and private sector
research and policy with research, analysis, and state-of-the art geo-mapping
that are supported by a proprietary data warehouse containing vital
statistics, demographics, provider claims, prescribing patterns, clinical
laboratory values, and other essential data elements for every ZIP code in the
country. The Forum recognizes the need for a credible, objective and reliable
source of integrated data and expertise to strengthen national, state, and
local efforts to improve the quality of health care that is available to and
accessible by all populations in the United States. In support of this
mission, The Forum has pioneered the study of health care consumption patterns
for people living with chronic disease. The Forum is guided by a set of
principles that are designed to assure that the American health care research,
financing and delivery system: ï Is inclusive of, and assigns equal value to,
the healthcare and health status of all populations in the United States;
ï Creates market incentives for research and innovation that are responsive
to changing population demographics; and ï Places the quality and efficacy of
patient care, rather than cost, at the center of the clinical decision-making
process. The National Minority Quality Forum is taking this opportunity to
express concern about the processes employed to develop and validate these
measures, and, indeed, the very validity and relevance of these performance
measures to efforts to create a 21st century health services research,
delivery and financing system in the United States that is responsive to the
health and medical needs of the patient and health care consumer populations
of the 21st century. The National Minority Quality Forum assumes
responsibility for assuring that our stakeholders understand the way in which
the American system of developing and delivering health services is understood
by the consumers whose interests should be at the core of all discussions and
transactions. We find that the current process of developing, validating and
implementing quality and performance measures has evolved to a stage at which
it represents the antithesis of transparency and true engagement. It is an
oroburous-like process-- folding in upon itself in a way that prohibits any
real input or recognition of interests or systems that are not, essentially,
already ìof the bodyî. The National Minority Quality Forum is particularly
concerned that bio-diversity, heterogeneity of treatment effect, and
variability of disease presentation and progression in different populations
are not factored into the performance measures. In the best of circumstances,
performance measures are rooted in clinical guidelines. In the case of
clinical guidelines, randomized double-blinded clinical trials are the gold
standard by which standards of care are determined. Unfortunately, the lack of
diversity in clinical trials means that clinical guidelines are often not the
foundation upon which clinical care for diverse populations is obtained. It is
clinician experience that is needed to fill the gap created by the lack of
diversity in clinical trials. Performance measures all too frequently gloss
over the diversity limitation of clinical guidelines, and in the process raise
the potential of inducing health systems to provide less than optimal care to
diverse population. These are our suspicions, and we find no evidence in any
of the measures that they acknowledge patient variability, the limitation of
the science, or the need to demonstrate that the measure has the capacity to
provide optimal care to diverse population. We cannot, therefore, communicate
to our consumer and patient constituents confidence in the National Health
Council process, or, by extension, the manner in which the Department of
Health and Human Services monitors and reports the effectiveness of health
programs that are supported by public funds amassed through the collection of
taxes. We believe it is incumbent upon the National Health Council and the
Department of Health and Human Services to take the initiative to meet with us
and our members and inform us of the manner in which these issues have been
factored into the performance measurement process. Please read these comments
as our declaration of concern about the ability of any of these measures and
the process that produced them to ensure quality of care to Americaís emerging
majority. We will make ourselves available to assist you in this process.
Sincerely, Gary A. Puckrein, PhD President and CEO National Minority Quality
Forum (Submitted by: National Minority Quality Forum )
- Novo Nordisk, Inc. (ìNovo Nordiskî) appreciates the opportunity to provide
comments on MAPís draft programmatic deliverable report. Novo Nordisk supports
MAPís identification of ìhigh-value measuresî for CMS programs. As indicated
in this report on page 43 (Table 1), gap areas still remain in the Physician
Quality Reporting System (PQRS) Program for outcomes, patient-reported
outcomes, and patient experience measures for many conditions. Novo Nordisk
supports the development and use of these measure types to further advance
outcomes for diabetic patients. Novo Nordisk encourages the MAP to continue to
support these measures for the PQRS program, given the impact on numerous
disease states, including diabetes. (Submitted by: Novo Nordisk)
- Novo Nordisk, Inc. (ìNovo Nordiskî) appreciates the opportunity to provide
comments on MAPís draft programmatic deliverable report. Novo Nordisk supports
MAPís identification of gap areas for measurement, and would like to encourage
the Partnership to identify additional gap areas for specific conditions. In
particular, Novo Nordisk urges MAP to formally identify obesity as a gap area.
Obesity is an area which has not been adequately addressed by measures
currently implemented in national reporting programs administered by the
Centers for Medicare and Medicaid Services (CMS). The Centers for Disease
Control and Prevention (CDC) estimates that 78.6 million in the U.S. are
obese, with an associated cost of $147 billion annually. Obesity increases
risk for several other conditions, including heart disease, stroke, cancer,
and type 2 diabetes. To align with efforts initiated by key national
stakeholders (including the American Medical Association, which adopted a
policy that recognized obesity as a disease in 2013) MAP should consider
formally identifying measure gap areas to address obesity given its impact.
(Submitted by: Novo Nordisk)
- [Pre-workgroup meeting comment] Florida Hospital would like to
address the short time from to make relevant comment on the list of Measures
under consideration. There are some 200 measures listed in a 300 page
document. We do not find it possible to provide any meaningful comment in
four days. There appears to be many important items in the Measures Under
Consideration. We trust that providers such as we will be give adequate time
to asses the various items. Richard Morrison, Vice President Adventist Health
System(Submitted by: Florida Hospital)
- [Pre-workgroup meeting comment] The Infectious Diseases Society of
America (IDSA) appreciates the opportunity to provide comments on the Measures
under Consideration (MUC) list that will be reviewed by the Measure
Applications Partnership (MAP) Clinician Workgroup< which will be
evaluating such measures for use in future federal reporting programs. IDSA
supports the use of the following measures in future federal reporting
programs, X3816 - Hepatitis C: Appropriate Screening Follow-Up for Patients
Identified with Hepatitis C Virus (HCV) Infection X3512 - Hepatitis C:
One-Time Screening for with one or more of the following: a history of
Hepatitis C Virus (HCV) for Patients at Risk X3300 - HIV Screening of STI
patients X3299 - HIV: Ever screened for HIV X3513 - Annual Hepatitis C Virus
(HCV) Screening for Patients who are Active Injection Drug Users E2082 - HIV
Viral Load Suppression E2079 - HIV medical visit frequency E2083 -
Prescription of HIV Antiretroviral Therapy We are in support of use of these
measures despite not having been reviewed or endorsed by NQF, as they fill
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs. IDSA has reservations regarding the use of the following measures,
E2158 - Payment-Standardized Medicare Spending Per Beneficiary (MSPB) X0354 -
Cellulitis Clinical Episode-Based Payment Measure X0351 - Kidney/Urinary Tract
Infection Episode-Payment Measure We would like to reiterate our sentiments
expressed in our comment letter to the 2015 Physician Fee Schedule Proposed
Rule, which stated our concerns over the cost attribution methodology for the
Payment-Standardized Medicare Spending Per Beneficiary (MSPB) measure. In
particular, this measure holds physicians accountable for the totality of
costs associated with the care of a patient, which incorrectly assumes that
physicians have control over the care plan and treatment decisions of other
physicians who also treated the patient over the reporting year. We are
encouraged that CMS has included condition-specific episode of care measures
on the MUC list but, until thorough validity and reliability testing has been
performed in settings of prospective use, we will continue to have concerns
over these efficiency measures. Specific to the Cellulitis and UTI measures,
IDSA was never formally asked to contribute expert volunteers to these cost
measure development panels despite the topic relevancy to ID-care. As a
result, IDSA is unsure to what extent they were developed with appropriate/
relevant clinical expertise. In our comment letter, we recommended that CMS
gradually incorporate episode-based and condition-specific cost measures into
federal quality programs by initially using this data only for confidential
provider feedback reports. We feel this will give CMS and providers time to
evaluate and potentially make changes to the accuracy, relevance, and format
of these measures prior to using them for accountability purposes. Therefore,
we ask that NQF consider evaluating these measures for the purpose of
time-limited endorsement and that the MAP recommend to HHS that these measures
initially only be used in confidential feedback reports and not for
accountability purposes.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment on the measures under consideration for the annual review of measures
for Federal programs. The Childrenís Hospital Association offers two general
comments and will follow the work of the MAP workgroups in reviewing specific
measures. We urge MAP and CMS to give strong preference to measures that have
been endorsed by the National Quality Forum. In reviewing measures that are
not yet endorsed or not submitted for endorsement, we believe it is important
to assess if there are similar endorsed measures available and to identify a
pathway to critical review and endorsement. The Childrenís Hospital
Association is pleased that the age groups to which the measures are applied
are included in many of the measure titles and measure descriptions. As CMS
makes decisions about measures to be included in Federal programs, we
encourage consistency in clearly identifying applicable patient populations.
(Submitted by: Children's Hospital Association)
- [Pre-workgroup meeting comment] Submitted New Measure: ìAssessment
of Psoriasis Disease Activityî Status: submitted for CMSís Call for measures
MUC list Status: not included on the list The American Academy of Dermatology
encourages you to reconsider the inclusion of the measure ìAssessment of
Psoriasis Disease Activityî submitted for consideration in 2016 PQRS but not
included on the list of Measures Under Consideration. This measure evaluates
the percentage of patients with psoriasis whose disease activity has been
evaluated and documented at least once yearly. Assessment of psoriasis
disease activity is critical for guiding treatment choice, determining
treatment response, and, thus, measuring quality of care. This measure will
assess psoriasis activity or severity using different measurement indices
including the patient-reported quality of life measure, Dermatology Life
Quality Index (DLQI). Several of the suggested disease activity measures are
used regularly in clinical trials to determine the efficacy of psoriasis
therapies, and this measure would encourage the use of such measures in
clinical practice, which has high potential for improving clinical and patient
reported outcomes. This performance measure is critical to the success of
measure X3726 (Clinical Response to Oral Systemic or Biologic Medications) and
to the development of additional outcome measures and comparative
effectiveness studies which rely on regular assessment and documentation of
disease activity and patient-reported outcomes measures. Together, this
measure and measure X3726 have great potential to improve the quality of care
for patients with psoriasis. Dermatology care currently has very few PQRS
measures, including only one measure related to psoriasis. This measure was
developed as a set of Psoriasis measures that complement each other. This
other measures in the psoriasis set are: Measure #337 Tuberculosis Prevention
For Psoriasis, Psoriatic arthritis patients on a biological immune response
modifier; measure X3274; and measure X3726. Adding this measure would maintain
the measures as a set, providing within PQRS a collection of psoriasis
measures. This set of measures would allow more reporting on the care for
psoriasis, the most prevalent autoimmune disease in the U.S., affecting about
7.5 million Americans. (Submitted by: American Academy of
Dermatology)
- [Pre-workgroup meeting comment] Submitted New Measure:
Documentation of discussion with patients about potential use of
field-directed therapies prior to destruction of Actinic Keratoses (17004
code) MUC list Status: not included on the list The Academy of Dermatology
encourages you to reconsider the inclusion of the measure ìDocumentation of
discussion with patients about potential use of field-directed therapies prior
to destruction of Actinic Keratoses (17004 code)î submitted for consideration
in 2016 PQRS but not on the list of Measures Under Consideration. Actinic
keratoses are the second most common diagnosis made by dermatologists in the
United States, accounting for 15.3% of visits. When treating multiple visible
or subclinical actinic keratosis (AK) lesions, applying field-directed therapy
is an effective treatment option that greatly reduces further AK development
and may reduce the risk of squamous cell carcinoma. Field-directed therapies
such as topical chemotherapeutics, photodynamic therapy, and chemical peels
have been shown to also be cost-effective as they account for only 6% of the
$920 million spent on AK treatment annually despite being used for 26% of
patients. Two-thirds of patients reflect a preference for field-based
therapies treatments. The ability of field treatments to provide lower-cost
treatment that reduces clinical and sub-clinical lesions has made it core part
of treatment of actinic keratoses. Discussing the potential benefits of field
therapies with patients who have numerous actinic keratoses may not only
improve the efficiency of treatment, but the patientís experiences and
outcomes. Additionally, by encouraging patient-physician discussion, this
measure encourages shared decision making between the provider and patient,
while soliciting patient input for field directed therapies. Patient input is
critical for patient satisfaction and positive patient reported outcomes. More
importantly, this measure saves health care costs and lives by not only
preventing advanced stage cancers which are harder to treat and have higher
mortality rates, but also reducing the need for use of advanced technologies
associated with advanced cancer stages. In addition, this measure will
facilitate the development of a future patient-reported outcome measure
focused on actinic keratosis treatment. Currently there are few PQRS measures
of dermatologic care and no measures related to actinic keratosis. Adding this
dermatology-specific cost-saving and patient reported measure to PQRS, not
only helps dermatologists to achieve successful reporting and avoid penalties
for under-reporting for programs such as PQRS and the Value Based Payment
Modifier, but also (and more importantly) to contribute to the quality and
performance goals of CMS.(Submitted by: American Academy of
Dermatology)
- [Pre-workgroup meeting comment] The Leapfrog Group, including our
board and members, comprise hundreds of the leading purchaser and employer
organizations across the country. We are committed to improving the safety,
quality, and affordability of health care through the use of hospital
performance information to inform consumer choice, payment, and quality
improvement. We are one of the few organizations that both collects and
publicly reports quality data on a national level, so we bring a perspective
from the trenches on what measures would be most effectively collected and
reported. Thus we appreciate the opportunity to submit comments to the on the
most recent CMS MUC list. General Comments Related to the Ambulatory Surgical
Center Quality Reporting Program and Outpatient Quality Reporting Program
Leapfrog strongly supports the addition of measures to both the Ambulatory
Surgical Center Quality Reporting Program and the Outpatient Quality Reporting
Program, but would strongly urge CMS to consider aligning measures between the
two programs. As the number of consumers enrolled in high-deductible health
plans increases, more and more consumers are looking for cost-effective, high
quality options for care. There are often significant differences in price for
the same procedure if performed in a hospital-based outpatient department or a
free-standing ambulatory surgical center. However, there is no way for a
consumer to compare the quality or safety of these two options. In addition,
Leapfrog would urge CMS to seek out and/or develop measures of complications
that occur 30, 60, and 90-days following a procedure at an Ambulatory Surgical
Center. General Comments Related to All Hospital-Based Reporting Programs
First, in order for measures to be actionable for consumers, data must be
collected and reported out at the facility level, not the system level (e.g.
by Medicare Provider Number). Consumers cannot adequately gauge their risk of
harm when measures are reported at the system level and include aggregated
data from two or more facilities. Leapfrogís own hospital Survey requires
facility-level reporting, and survey results show that there are significant
variances in hospital performance, even among facilities within the same
system. Next, Leapfrog strongly urges that the new measures of cost and
resource use be paired with safety, quality, or outcome measures. Without the
appropriate safety, quality, and outcome measures to accompany cost
information, consumers cannot make fully informed, safe decisions about where
to receive care. Lastly, based on the current CMS MUC List, Leapfrog, our
board, and our members remain concerned regarding the significant gap in the
public reporting of hospital-acquired conditions. Since CMSí decision to
remove the eight hospital-acquired conditions measures from the IQR program,
we continue to await promised replacement measures, and none have emerged.
Though we support the addition of the AHRQ Patient Safety Indicators, there
are still gaps in information for consumers and purchasers. We have serious
concerns about the following gaps: 1) Inadequate reporting on (a) Foreign
Object Retained After Surgery (b) Air Embolism, and (c) Falls and Trauma. CMS
removed these Hospital Acquired Conditions from the IQR and announced the
intention to remove them from all public reporting. These are very important
errors and accidents that the public deserves to know about. 2) The absence
of measures that focus on medication errors, which are the most common error
made in health care. 3) The absence of measures that address appropriate use,
a problem identified by the National Priorities Partnership as one of the six
priority challenges in U.S. healthcare. 4) The inadequacy of measures of
pediatric, maternity, orthopedic, and oncology care. 5) The inadequacy of
measures of patient-reported outcomes, and meaningful patient engagement,
which are critical to patients. (Submitted by: The Leapfrog
Group)
- [Pre-workgroup meeting comment] December 5, 2014 The National
Quality Forum Measure Applications Partnership (MAP) Coordinating Committee
1030 15th Street NW Suite 800 Washington DC 20005 Attention: Committee
Co-Chairs George J. Isham, MD, MS Elizabeth A. McGlynn, PhD, MPP Re: 2014
Measures Under Consideration (MUC) Comments Dear MAP Coordinating Committee
Members: The Healthcare Leadership Council (HLC) respectfully submits these
comments in connection with The Centers for Medicare & Medicaid Services
(CMS) issued List of Measures under Consideration (MUC) (the List) to comply
with Section 1890A(a)(2) of the Social Security Act (the Act), which requires
the Department of Health and Human Services (DHHS) to make publicly available
a list of certain categories of quality and efficiency measures that it is
considering for adoption through rulemaking for the Medicare program. In this
response, we (i) provide background on HLC and (ii) offer a response to the
request for early public comments for the 2014 Measures Under Consideration
(MUC) as well as broad public feedback to guide the individual MAP workgroups
in their deliberations prccess. Background HLC, a coalition of chief
executives from all disciplines within American healthcare, is the exclusive
forum for the nationís healthcare leaders to jointly develop policies, plans,
and programs to achieve their vision of a 21st century system that makes
affordable, high-quality care accessible to all Americans. Members of HLC ñ
hospitals, academic health centers, health plans, pharmaceutical companies,
medical device manufacturers, biotech firms, health product distributors,
pharmacies, and information technology companies ñ envision a quality-driven
system that fosters innovation. HLC members advocate measures to increase the
quality and efficiency of American healthcare by emphasizing wellness and
prevention, care coordination, and the use of evidence-based medicine, while
utilizing consumer choice and competition to elevate value. Comments The
Affordable Care Act (ACA) made major changes to the Medicare program. These
changes will move our healthcare system away from a payment system that pays
providers for the volume of services to one that rewards providers, in part,
based on the quality and outcomes of their services. As a result of the ACA,
six percent of hospitalsí payments will be subject to a performance standard:
three percent for hospital readmissions, two percent for value-based
purchasing, and one percent for hospital-acquired conditions (HAC).
Medicareís Hospital Readmission Reduction Program (HRRP) links risk-adjusted
hospital readmission rates to financial penalties. Hospitals with
risk-adjusted readmission rates that fall below the national average are
penalized by having their annual Medicare payments reduced by up to three
percent. In 2015, hospital payments are scheduled to be reduced by up to
three percent. In FYs 2013 and 2014, hospitals that exceed expected
readmission rates for heart attack, heart failure and pneumonia have payments
for all DRGs reduced by up to one and two percent, respectively. For FY 2015
and subsequent years, hospitals with higher than expected readmission rates
for these conditions, as well as chronic obstructive pulmonary disease (COPD)
and elective total hip/total knee arthoplasty will have their payments reduced
by up to three percent. Risk adjustment is one way to statistically control
for factors that lie beyond a providerís scope of care. HRRP currently applies
a risk adjustment formula that includes factors such as a patientís gender,
age and health status, but does not include what are referred to as social
determinants of health that are captured in a patientís socioeconomic status
(SES) with factors such as income and education. The Hospital Readmission
Reduction Program has only one measure currently under consideration. HLC is
concerned that pay-for-performance penalties are having a disparate impact on
hospitals that serve low-income areas. More than any other hospital metric,
readmissions are influenced greatly by factors beyond the hospitalís control,
and studies have demonstrated that the challenges faced by urban and rural
low-income populations directly impact these outcomes. Numerous analyses have
found that safety net hospitals , which care for low-income patients, are more
than twice as likely to be penalized as hospitals caring for higher-income
patients. After controlling for quality of care, hospitals serving large
shares of low-income patients consistently have higher readmission rates than
their wealthier peers. Low-income patients often lack the support to keep
them out of the hospital and/or to help them become healthier. This is due to
a myriad of issues, including: weaker social networks, cultural and linguistic
challenges, high levels of homelessness, high illiteracy rates, and poor
access to auxiliary health care services and pharmacies. A hospitalís
readmission performance is calculated using NQF-endorsed risk-adjusted 30-day
measures for AMI, heart failure and pneumonia. NQF recognized that outcomes
are influenced by many factors other than care and services received, so there
are adjustments for clinical factors such as comorbidity and severity of
illness. However, these measures do not adjust for the socio-economic status
of the hospitalís patient population. NQF has recognized the possible
consequences of this omission and has published a report suggesting
socio-economic risk adjustment for certain quality measures where there is a
conceptual relationship and an empirical basis. HRRP penalties can be
significant and add to the financial challenges already facing safety net
hospitals. HLC is concerned that this may lead to unintended consequences,
such as hospital closures in areas where few providers operate ñ which in
turn, could worsen health disparities rather than alleviate them among
Medicare beneficiaries who live in low-income areas. Given the potential for
inadvertent consequences, pay-for-performance programs must be carefully
designed to ensure at a minimum that health disparities are not exacerbated.
Programs should accurately measure the performance of providers for whom
payments are put at risk while controlling for factors that are outside a
providerís sphere of influence. In the case of hospital readmission rates,
the scope of the quality measure (rate of readmissions 30 days after hospital
discharges) is too broad to isolate the effect of a hospitalís role because
many significant social and demographic factors come into play after
discharge. The Medicare Payment Advisory Commission (MedPAC) is considering a
new approach to measuring and reporting on the quality of care within and
across the three main payment models in Medicare: Fee-For-Service Medicare,
Medicare Advantage, and Accountable Care Organizations (ACOs). In MedPACís
June 2014 Report the Commission remarked on an initial study of the
feasibility of calculating population-based outcome measures for Medicare, in
which they worked with a contractor to calculate rates for potentially
preventable admissions (PPAs) and potentially preventable visits (PPVs) to
emergency departments. The results of that initial analysis indicated that it
is feasible to use FFS Medicare claims data to calculate rates of PPAs and
PPVs. These rates demonstrate that Medicare could set a more specific
performance benchmark in each local area. Additionally, NQF draft
recommendations would require CMS to account for patient socio-economic status
when calculating the risk-adjusted readmissions penalties. The National
Quality Forumís Technical Report issued August 15, 2014, Risk Adjustment for
Socioeconomic Status or Other Sociodemographic Factors, stated that: ìThere is
a large body of evidence that various sociodemographic factors influence
outcomes, and thus influence results on outcome performance measures. There
also is a large body of evidence that there are disparities in health and
healthcare related to some of those sociodemographic factors. Given the
evidence, the overarching question addressed in this project is, ìWhat, if
anything, should be done about sociodemographic factors in relation to outcome
performance measurement?î This project did not include recommendations for
specific performance measures: adjustment for determining payment for services
provided, such as capitated payments; use of particular risk adjustment or
statistical procedures; or structuring performance/reward penalty programs
such as pay-for-performance. It recommended that the NQF should define a
transition period for implementation of the recommendations related to
sociodemographic adjustment. The CEOs of the Healthcare Leadership Council
are strongly committed to reducing unnecessary readmissions to our nationís
hospitals, and believe that hospitals should be held accountable for the
quality of their care. However, we urge the MAP Committee to consider
measures that will ensure hospitals serving low-income populations are
evaluated and reimbursed fairly. Including patientsí socioeconomic status as
part of the list of measures under considerations can improve the quality of
care, increase payment accuracy for all inpatient hospitals, and better manage
patients affected by factors outside the hospitalís control. HLC appreciates
this opportunity to comment on the Measures Under Consideration. We believe
there is tremendous potential for the health care industry as a whole to bring
about robust collaboration and quality improvement in Medicare and Medicaid,
both of which will be critical to achieving our mutual goal of improving the
value of healthcare delivery for all. Sincerely, Mary R. Grealy President,
Healthcare Leadership Council(Submitted by: Healthcare Leadership
Council)
- [Pre-workgroup meeting comment] Based on the titles of some
measures, it appears there are measures under review that are duplicative to
existing measures in CMSí physician programs. We request for the MAP to review
measures for potential redundancy and to reach out to the measure developer to
find out the necessity for proposing a similar measure in a physician program.
For example, X3792: controlling high blood pressure. Given the number of
measures that are now in physician programs, it would be helpful for CMS to
further classify the measures by which physician specialty is intended to
report on the measure. (Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] Physician Electronic Health Record
Incentive Program: Overall, we are concerned with the feasibility of capturing
these measures in the EHR. We are well aware of the inability of EHRs to
capture the patient reported outcomes measures and ability to collect patient
data over time. Therefore we recommend: Before new measures go forward that
there is real-world testing in multiple types of physician practices settings
and sizes to ensure the EHR can capture and calculate the measures without
putting an undue burden on physicians; ï If CMS moves forward with the new
quality measures, CMS should consider these measures in the beta-phase and not
hold physicians accountable until we learn more about the feasibility of the
measures. Physicians should have the opportunity to report on the measures
for three years, at a minimum, before they are held accountable.(Submitted by:
American Medical Association)
- [Pre-workgroup meeting comment] Physician Programs: Section 218 of
the Protecting Access to Medicare Act of 2014 (PAMA) includes a provision that
beginning Jan. 1, 2017 will require physicians ordering certain imaging
services to consult appropriate use criteria for advanced imaging services
(MRI, CT, nuclear medicine and PET). Physicians who furnish the imaging
service will be required to specify on the claim which qualified clinical
decision support mechanism was used to consut the appropriate use criteria and
whether the service ordered adheres to the criteria. A question that MAP
should consider as it addresses the measures CMS has submitted is how the
imaging-related measures being proposed will interact with the new PAMA
requirement.(Submitted by: American Medical Association)
| (Program: Medicare Shared Savings Program; MUC
ID: E0052) |
- This measure, under consideration for the Medicare Shared Savings Program
(MSSP), looks at 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 AANS and CNS agree with the MAPís recommendation
of ìnon-support.î The MAP does not support it because it only applies to ages
18-50 years and fails to target the current gap in measures for overuse of
imaging for low back pain in the older population. However, we also believe
the measure fails to incorporate critical caveats or ìred flagsî among low
back pain patients that may appropriately drive early imaging(Submitted by:
American Association of Neurological Surgeons/Congress of Neurological
Surgeons)
| (Program: Medicare Shared Savings Program; MUC ID:
E0055) |
- This measure is inconsistent with the care process guidelines developed by
the American Academy of Ophthalmology for diabetic retinopathy. This measure
calls for initial eye exams in an untimely manner, too frequently or
prematurely for individuals with Type 1 diabetes, and not early or frequent
enough for individuals with Type 2 diabetes. Therefore, the Academy encourages
the measure owner to make the appropriate modifications to reflect the
evidence published in guidelines.(Submitted by: American Academy of
Ophthalmology)
- The American Optometric Association strongly supports the use of the
diabetic eye exam measure (NQF 55) in the Shared Savings Program. We believe
inclusion of this measure is helpful for ACOs who may not be aware of the cost
of preventable diabetes complications that could be avoided by good eye care.
The serious burden of diabetes on the Medicare population cannot be
overlooked. According to the Centers for Disease Control and Preventionís
(CDCís) National Diabetes Statistics Report for 2014, approximately 25.9
percent of adults age 65 and older have diabetes. The CDC has also indicated
that from 2005ñ2008, of diabetic adults age 40 and older, 4.2 million (28.5
percent) had diabetic retinopathy. Additionally, during that same time period,
of adults with diabetes aged 40 years or older, 655,000 (4.4 percent) had
advanced diabetic retinopathy with potential for severe vision loss.1 Research
demonstrates a serious gap in care remains because as many as 1/3 to 1/2 of
persons with diabetes donít receive an annual eye examination.2,3 Furthermore,
the CDC reports that among U.S. adults aged at least 20 years old with
diabetes, 11.0 percent had visual impairment (i.e., presenting visual acuity
worse than 20/40 in their better-seeing eye while wearing glasses or contact
lenses, if applicable) and approximately 65.5 percent of these cases of visual
impairment were correctable.4 Access to eye examinations for individuals with
diabetes is critical in reducing falls and hospital readmissions, thus
physicians and patients with diabetes should become more aware that poor
vision often is correctable and that visual corrections can reduce the risk
for injury and improve the quality of life for persons with diabetes. The AOA
recently developed clinical practice guidelines for eye care of the patient
with diabetes mellitus that also emphasizes the critical need for annual eye
examinations for patients with diabetes. The AOAís evidence-based guideline
was developed by an internationally recognized, interdisciplinary panel of
leading eye care practitioners, health policy experts and patient advocates.
The guideline states, ìIndividuals with diabetes should receive at least
annual dilated eye examinations. More frequent examination may be needed
depending on changes in vision and the severity and progression of the
diabetic retinopathy.î5 The medical community is in agreement regarding the
need for annual eye examinations for patients with diabetes and the Shared
Savings Program should reflect this consensus. The Diabetes Advocacy Alliance
(DAA) has also issued strong guidance with regard to eye care for patients
with diabetes. The DAA is dedicated to addressing the challenges that diabetes
and prediabetes pose to the health of Americans and the U.S. economy. The DAA
is comprised of 20 members including the AOA, the American Medical
Association, the American Diabetes Association and the Medicare Diabetes
Screening Project (MDSP). The DAA indicates, "Ultimately, the best way to
prevent developing eye complications from diabetes is to have your eyes
examined annually, and control blood glucose levels and blood pressureÖ.it is
essential that all newly-diagnosed individuals with type 2 diabetes receive a
comprehensive eye examination from an optometrist or ophthalmologist within
three months of diagnosis. Additionally, people with diabetes should receive
annual dilated eye exams."6 The inclusion of the eye exam measure in the
Shared Savings Program will help to ensure that the millions of Medicare
patients with diabetes are receiving appropriate recommended eye care as part
of their overall diabetes care. Furthermore, including the diabetic eye exam
measure in the Shared Savings Program may also help to curb the growing number
of adults with diabetic retinopathy. The increase in Americans with diabetes
has contributed to an increase in the number of adults with diabetic
retinopathy. Between 2000 and 2010, the number of adults with diabetic
retinopathy rose 89 percent.7 Diabetic retinopathy is the leading cause of
blindness among adults aged 20 to 74 years.7 The Diabetes Advocacy Alliance
indicates that 7.7 million adults aged 40 and over suffer from diabetic
retinopathy and if this trend continues it is estimated that approximately 13
million Americans aged 40 and over will have visual impairment or develop
blindness from diabetes by 2050. While the MAP has indicated they support
continued development of this measure, the AOA is committed to addressing the
diabetes epidemic and strongly supports use of the diabetic eye exam measure
in the Shared Savings Program. (Submitted by: American Optometric Association
)
- [Pre-workgroup meeting comment] The Academy would like to reiterate
its past concerns with this measure that is already included in the PQRS
program because this measure is inconsistent with the care process guidelines
developed by the American Academy of Ophthalmology for diabetic retinopathy.
This measure calls for initial eye exams in an untimely manner, too frequently
or prematurely for individuals with Type 1 diabetes, and not early or frequent
enough for individuals with Type 2 diabetes. Individuals with Type 1 diabetes
should have annual dilated eye examinations beginning 5 years after the onset
of diabetes, as substantial retinopathy may become apparent as early as 6 to 7
years after onset of the disease. Individuals with Type 2 diabetes mellitus
should have a dilated eye examination at the time of diagnosis of Type 2
diabetes, and subsequently should have an annual dilated eye examination to
detect the onset of diabetic retinopathy. Up to 3% of patients whose diabetes
is first diagnosed at age 30 or later will have CSME or high-risk features at
the time of the initial diagnosis of diabetes. About 30% of patients will
have some manifestation of diabetic retinopathy at diagnosis. Therefore, the
patient should be referred for ophthalmologic evaluation at the time of
diagnosis.(Submitted by: American Academy of Ophthalmology)
| (Program: Medicare Shared Savings Program; MUC ID: E0056)
|
- Novo Nordisk, Inc. (ìNovo Nordiskî) appreciates the opportunity to provide
comments on MAPís preliminary recommendations. Novo Nordisk commends the MAP
on their support of including E055 Comprehensive Diabetes Care: Foot Exam in
the Medicare Shared Savings Program (MSSP) only as part of a composite. Novo
Nordisk urges the MAP to further specify in its recommendation that before
this measure is included as a composite measure in the MSSP program it should
be tested, validated, and submitted for NQF endorsement to ensure that
composite status is appropriate for use. Ensuring that this measure meets the
criteria of a composite measure will be important prior to utilization in
clinical practice.(Submitted by: Novo Nordisk)
| (Program: Medicare
Shared Savings Program; MUC ID: E0070) |
- Unclear why documentation for not prescribing aspirin or clopidogrel are
exclusion criteria as this is a measure for beta blocker therapy. Recommend
deleting this exclusion criteria. (Submitted by: AstraZeneca
Pharmaceuticals)
- The MAP has not been consistent in labeling process measures as ìnarrowî
in scope. The measures should be judged based on evidence for their link to
survival/quality of life. Using this criteria, this measure would be viewed
as very important.(Submitted by: American Heart Association/American Stroke
Association)
| (Program: Medicare Shared Savings Program; MUC ID: E0076)
|
- See comments for PQRS.(Submitted by: SMT)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: E0076)
|
- We support the composite approach with this measure and the description of
the measure with four criteria required to achieve compliance. However, we
cannot support the measure as it is written with the exclusion of ëLDL less
than 100í as part of the numerator. It is not a complete measure. The title
is not consistent with the measure specifications which makes it misleading to
the clinician and the patient. The title implies LDL will be measured as
important to ëoptimal vascular careí which will address all the elements of
care that have been demonstrated in the literature to be related to optimal
outcomes if followed by the clinician and patient. However, one of the
elements which has been identified as related to ASCVD risk and poor outcomes
has been removed. It creates a confusing message for patients and undermines
clinician efforts to address ASCVD risk and cholesterol treatment. In
addition, it is an incomplete measure. A composite measure is evaluated based
on the total combination of its elements, not as individual measures but in
combination. This measure is missing an important element, the LDL level.
Removing 1 element from the composite requires that the measure be
re-evaluated to determine the evidence for its impact without this element,
whether it has the same potential for impact on the quality of care and
patient outcomes. In addition, if there were a number of years in which the
LDL was included; now it has been removed. The information from NQF on this
measure is that MN Community Development is reviewing the measure and will
make changes in the future, the LDL will possibly be added back in. This
shifting in how the measure is specified makes its use for analysis of the
impact of the measure on care and patient outcomes invalid. Trending data will
be impossible to interpret. Although specific LDL-C treatment goals are not
recommended in the guideline, LDL levels are still clinically important. In
those people not at high risk because of existing ASCVD or an LDL >190
mg/dL, the guideline recommends treatment with statins for those with an LDL
> 70 mg/dL. The opposition to use of an absolute LDL of 100 mg/dL was
partly based on the concern that it would result in ëundertreatmentí of those
who may have an LDL close to the target who should still be on a high
intensity dose. There are multiple statements in the ACC/AHA 2013 guidelines
about the importance of lowering the LDL: ï ìMoreover, statin therapy
reduces ASCVD events across the spectrum of baseline LDL-C levels =70 mg/dL.î
(S7) ï ìClassifying specific statins and doses by the percent reduction in
LDL-C level is based on evidence that the relative reduction in ASCVD risk
from statin therapy is related to the degree by which LDL-C is lowered.î
ï ìÖextensive evidence shows that each 39-mg/dL reduction in LDL-C by statin
therapy reduces ASCVD risk by about 20%.î (P S14) ï The priority of the
guideline is on prescribing high intensity dosing. The information in the
Full Report provides an idea of how that translates into clinical practice and
LDL levels. It reports that in the clinical studies ìhigh-intensity statin
therapy resulted in mean LDLñC levels of 53 to 79 mg/dL on treatment, with the
large majority of participants in the high-intensity statin group achieving an
LDLñC <100 mg/dLî The statin intensity recommendations are benchmarked
against expected LDL-C reductions (i.e. >50% high; 30% to <50% moderate)
as indicators of response to therapy. Considering variations in statin
response, tolerability, patient biological variability, adherence, etc.,
measuring LDL-C (either directly or calculated) is necessary to confirm
patients are achieving treatment goals. To this end, the guideline recommends
monitoring response with lipid panels every 3 to 12 months (IA recommendation)
and appropriate treatment adjustment (Figure 5. Guidelines) Last, we believe
it is not warranted to change LDL-C quality measures based on a single
guideline; and a guideline that is not endorsed by other key expert groups and
societies dedicated to diseases of metabolism, including the National Lipid
Association (NLA) and the American Academy of Clinical Endocrinologists
(AACE). AACE has separate cholesterol guidelines that currently recommend
LDL-C <100 mg/dL in high risk patients including those with diabetes and
those with prior ischemic events. In summary, we do not support the use of
this measure with the removal of the LDL level from the composite measure. The
title is not consistent with the measure specification and implies that
cholesterol is an important part of ìOptimal Vascular Careî but it is not
actually included in the measure. Removal of the LDL screening and control
components of the measure without adding any means of evaluating
hyperlipidemia treatment seems counterproductive, misleading and harmful to
patients. While the ACC/ AHA guidelines do not identify a target LDL goal,
they do state that once statin therapy is initiated, monitoring should occur
using LDL levels to ensure optimal treatment selection and appropriate
decrease in LDL levels. We think it is important to maintain a measure
component to evaluate lipid treatment and monitoring in this patient
population. Finally, is one 1 element of a composite measure is removed, then
the validity, sensitivity and specificity of the measure needs to be
re-evaluated to determine whether it will still have the same level of impact
on the quality of care and improve patient outcomes. (Submitted by: SMT,
INC)
- ASN supports this measure in concept for individuals with CKD not
requiring dialysis but opposes inclusion of dialysis patients in this metric.
ASN is concerned though that dialysis patients would be included in this
metric as there are no data supporting any benefits to patients achieving the
proposed targets or from lipid-lowering medications. There are three large
clinical trials that have failed to show any reduction in risk for death with
lipid lowering therapies in patients undergoing dialysis. Consistent with
these findings, expert groups such as KDIGO and KDOQI do not recommend routine
testing and/or treatment for hyperlipidemia for patients undergoing dialysis.
(Submitted by: American Society of Nephrology (ASN))
- [Pre-workgroup meeting comment] We support the composite approach
with this measure and the description of the measure with four criteria
required to achieve compliance. However, the elements measured in the
numerator do not match those in the description of the measure. We cannot
support the measure as it is written with the exclusion of ëLDL less than 100í
as part of the numerator. The rationale for the removal of the LDL level was
provided in the NQF May 2014 update of the measure: the removal is based on
the 2013 AHA/ACC guidelines. The MN Community has indicated that it intends
to revise the measure in 2016 to be more consistent with the 2013 guidelines.
We believe this guideline and the totality of evidence does not support the
omission of the LDL-C target for several reasons. First, as described by the
Expert Panel, the guideline was not intended to provide for a comprehensive
approach to the detection, evaluation, and treatment of lipid disorders. The
Expert Panel acknowledges the importance of LDL-C and its causal role in the
genesis of CHD, and ASCVD, and as a basis for RCTs. Second, although
specific LDL-C treatment goals are not recommended in the guideline, the
statin intensity recommendations are benchmarked against expected LDL-C
reductions (i.e. >50% high; 30% to <50% moderate). Considering
variations in statin response, tolerability, adherence, etc., measuring LDL-C
(either directly or calculated) is necessary to confirm patients are achieving
treatment goals. To this end, the guideline recommends monitoring response
with lipid panels every 3 to 12 months (IA recommendation) and appropriate
treatment adjustment (Figure 5). Third, we do not believe the focus on choice
of therapy to the exclusion of LDL levels is consistent with the guidelines
and their intent. The charge of the Expert Panel was to address treatment of
blood cholesterol levels to reduce ASCVD risk. They have provided an ASCVD
risk calculator to determine a patientís initial risk and reduction in risk
based on improved parameters. The parameters used in calculating a personís
risk do not include use of statins or any other reference to treatment
methods. The parameters are clinical: they include the patientís LDL and HDL
level. We cannot avoid measuring and considering the absolute LDL if the
intent is to reduce risk and ASCVD outcomes. Last, we believe it is not
warranted to change LDL-C quality measures based on a single guideline; and a
guideline that is not endorsed by other key expert groups and societies
dedicated to diseases of metabolism, including the National Lipid Association
(NLA), American Academy of Clinical Endocrinologists (AACE), and American
Diabetes Association (ADA). AACE and ADA have separate cholesterol guidelines
that currently recommend LDL-C <100 mg/dL in high risk patients including
those with diabetes and those with prior ischemic events. In summary, we do
not support the use of this measure with the change to this measure as the new
referenced guideline is controversial and not endorsed by all relevant
specialty medicine professions, including the American Association of Clinical
Endocrinologists. Removal of the LDL screening and control components of the
measure without adding any means of evaluating hyperlipidemia treatment seems
counterproductive and harmful to patients. While the ACC/ AHA guidelines do
not identify a target LDL goal, they do state that once statin therapy is
initiated, monitoring should occur using LDL levels to ensure optimal
treatment selection and appropriate decrease in LDL levels. We think it is
important to maintain a measure component to evaluate lipid treatment and
monitoring in this patient population. (Submitted by: SMT, Inc.)
- [Pre-workgroup meeting comment] ASN supports this measure in
concept for individuals with CKD not requiring dialysis but opposes inclusion
of dialysis patients in this metric. ASN is concerned though that dialysis
patients would be included in this metric as there are no data supporting any
benefits to patients achieving the proposed targets or from lipid-lowering
medications. There are three large clinical trials that have failed to show
any reduction in risk for death with lipid lowering therapies in patients
undergoing dialysis. Consistent with these findings, expert groups such as
KDIGO and KDOQI do not recommend routine testing and/or treatment for
hyperlipidemia for patients undergoing dialysis.(Submitted by: American
Society of Nephrology (ASN))
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0141)
|
- The American Association of Nurse Anesthetists supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
falls and falls with injury. Both these outcome measures are critical to
improving patient safety. They fill a serious gap in falls measures on
Hospital Compare that consumer, purchasers, ANA and other stakeholders have
noted. The MAP report should be amended to reflect the broad Hospital WG
majority support (73%) vote for ìconditional supportî for these measures. As
outcomes measures, these measures are superior to claims based measures
because they are not subject to known coding issues (server under-reporting
with claims driven metrics), allow for timely reporting, and are clinically
enriched (e.g., clinical assessment data used). There are no harmonization
issues with other measures per CMS and AHRQ and fill a gap. (Submitted by:
American Association of Nurse Anesthetists)
- ANA supports the Hospital Workgroup (WG) vote of ìconditional supportî of
the NQF-endorsed measures falls (E 0141 and falls with injury and requests MAP
Draft Voting Report corrections: ? The MAP report should be amended to
accurately reflect the Hospital WG vote: o The only condition identified by
the MAP Hospital WG by the majority vote was NQF-endorsement for
hospital-level reporting. o CMS noted that neither CMS nor AHRQ consider the
measures as duplicative to any existing measure (no harmonization issue
exists). o The Hospital WG did not identify under-reporting related to falls
with injury. Additionally, the majority of HG WG members supported both
measures and are not concerned about issues with under-reporting. Rather,
they support a safety culture with reporting of both of these reliable and
valid measure endorsed by NQF. o Specifically, under-reporting was not an
agreed upon condition for the falls rate or the falls with injury measures. o
CMS and AHRQ do not see a harmonization issue with the
exisitng AHRQ PSI measure with either ANA falls mesaures (falls and falls with
injury) o Specifically, harmonization was not a condition
that was agreed upon or voted upon by the Hospital WG for either the ANA falls
or falls with injury measures(Submitted by: American Nurses Association
)
- There has been some criticism of the measures related to falls within an
institution as a marker of quality. The measure has importance if it is used
as a benchmarking statistic that guides the hospital/rehab center/SNF/LTAC to
development of identification of fall risk and institution of a fall
prevention program. A local example is the Episcopal Church Home in
Louisville that after reviewing its data implemented a risk assessment and
fall prevention program with a marked reduction in event.(Submitted by:
AmeriHealth Caritas)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- Would like the option to push data from NDNQI to CMS rather than
duplicative reporting. (Submitted by: Park Nicollet Methodist
Hospital)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. The proposed measure is an American Nurses
Association (ANA) developed nursing-sensitive safety measure developed to help
close the gap on the underreporting of falls in the current AHRQ Patient
Safety Indicator measure that only includes post-surgical hip fractures, which
is a small portion of the prevalent injuries from falls in hospitals. To more
accurately capture falls in hospitals, SEIU supports this measure which
incorporates a broader definition of falls. SEIU supports approval of these
proposed measures as gaps persist in capturing and reporting patient falls.
Taken together, these measures work in tandem for an effective falls and falls
with injury reduction program. As Hospital MAP work group members noted,
falls are a common adverse event in hospitals, with estimates of between 2-5
falls per 1,000 patient days. As the group noted this is an important area for
measurement as about 30% of falls result in injury, disability, or death.
Furthermore utilization of this measure will help the NQF Hospital MAP achieve
its objective of pursuing high value performance measures in hospital
accountability programs to get consumers the information they need to make
informed decisions about their health care. (Submitted by: Service Employees
International Union)
- SHM agrees with the MAP recommendation for conditional support, but notes
that there may be issues with data collection on falls and a risk of
under-reporting. This may inadvertently penalize institutions that have
prioritized accurate reporting and raises questions about how improvement can
be tracked.(Submitted by: Society of Hospital Medicine)
- The American Association of Colleges of Nursing supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
falls and falls with injury The MAP report should be amended to reflect the
broad Hospital WG majority support (73% vote for ìconditional supportî) for
these measures Both these safety outcome measures are critical to
improving patient safety They Fill a serious gap in falls measures on
Hospital Compare that consumer, purchasers, ANA and other stakeholders have
noted Are superior to claims based measures because they are Not
subject to known coding issues (server under-reporting with claims driven
metrics) and allow for timely reporting Clinically enriched (e.g.,
clinical assessment data used) Donít have harmonization issues with other
measures per CMS and AHRQ and fill a gap(Submitted by: American Association of
Colleges of Nursing)
- ? The ANA/NDNA supports the Hospital Workgroup (WG) vote of ìconditional
supportî of the NQF-endorsed measures falls and falls with injury and requests
MAP report corrections ? The MAP report should be amended to reflect the
Hospital WG vote accurately to reflect the following o The only condition
identified by the MAP Hospital WG by the majority vote was NQF-endorsement for
hospital-level reporting o CMS noted that CMS and AHRQ do not consider the
measures as duplicative to any existing measure (no harmonization issue
exists) o The Hospital WG did not identify under-reporting related to falls
with injury o Under-reporting was not an agreed upon condition for the falls
rate measure (Submitted by: ANA/NDNA)
- AGS notes that there is limited data to support any particular fall
prevention strategy in hospitals. Many frail elders are physiologic fallers ñ
and thus would be expected to experience some falls rate while hospitalized.
The strategies for these patients are safe, progressive, and aggressive
mobility programs. In addition, as the outcome of interest is injurious falls,
the use of an all falls measure is of questionable value, particularly as
reporting of falls is likely to be variable. AGS is concerned that mandating
hospital reporting would lead to under-reporting. Perhaps a better measure of
quality would be hospitalsí compliance with falls risk assessment (e.g. Morse,
Hendrich) and implementation of appropriate preventative measures, such as
eliminating tethers (iv lines, telemetry lines, urinary catheters), bed/chair
alarms, working call bells within patientsí reach, de-cluttering patientsí
rooms. (Submitted by: American Geriatrics Society)
- Understanding patient falls and preventing them is extremely important to
patients and families. Premier agrees with the importance of this measure but
disagrees with its public reporting. This is measure relies ultimately on
self-reporting by clinical staff. Publically reporting this measure is likely
to result in underreporting and is likely to drive certain the condition
underground. We agree that it is important to establish a culture of safety
in which staff feels safe to report harm and near-misses. However creation of
a culture of safety will not occur simply through mandatory publically
reporting. Reporting this measure has a high potential for unintended
consequences and should be used as in internal quality improvement tool, but
not a measure for public reporting. (Submitted by: Premier, Inc.)
- The American Association of Neuroscience Nurses (AANN) supports the
Hospital Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed
measures falls and falls with injury and requests MAP report corrections. The
MAP report should be amended to reflect the Hospital WG vote accurately to
reflect the following. o The only condition identified by the MAP Hospital WG
by the majority vote was NQF-endorsement for hospital-level reporting o CMS
noted that CMS and AHRQ do not consider the measures as duplicative to any
existing measure (no harmonization issue exists) o The Hospital WG did not
identify under-reporting related to falls with injury o Under-reporting was
not an agreed upon condition for the falls rate measure (Submitted by:
American Association of Neuroscience Nurses (AANN))
| (Program: Inpatient Rehabilitation Facilities Quality Reporting
Program; MUC ID: E0141) |
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- ARN realizes that falls in a hospital and rehabilitation setting present
significant risk for injury. All patients in rehabilitation are at risk of
falling. In fact, studies indicate that the rate of falls for acute care is 3
-6 falls per 1000 patient days versus the rate for inpatient rehabilitation
hospitals(IRF) vary between 2.92 ñ 17.8 falls per 1000 patient days (Gilewski,
Roberts, Hirata & Riggs, 2007; Mayo, Korner-Bitensky, Becker &
Georges, 1989). Thus IRFs have a higher rate just because of the nature of the
type of patient being admitted. Patients admitted with a stroke, spinal cord
injury, brain injury, amputations and neurologic impairments have demonstrated
a higher fall rate than patients admitted to an IRF with cardiac, pulmonary
and orthopedic disorders (Forrest, et al., 2012). Furthermore, impulsivity is
a common consequence of individuals with stroke and brain injury and can
impede patient progress and recovery. Such cognitive impairment has been
shown to be a leading risk factor for falls in older adults (Hitcho et al.,
2004; Hong, Cho & Tak, 2010). Individuals with cognitive impairment are
at a greater risk of injury from falling (Holtzer et al., 2007; Rochat et al.,
2008). Staffing ratios may also affect fall rate as well. Some studies have
shown that hospital units that had more than five patients per nurse had
higher fall rates than units with five or fewer patients per nurse (Krauss et
al., 2005). Looking at falls rates without looking at all of the above
mentioned components would not be helpful. There are many confounding factors
that may not be able to give an adequate comparison for a pay for performance
model. Therefore, falls benchmarks are not one size fits all. We request that
the IRF fall rate consider these factors and compare IRF fall rates to only
other IRFs. In addition, stratification and analysis of patient populations
(stroke, brain injury, etc) would be helpful in providing additional insight
and benchmarks. (Submitted by: Association of Rehabilitation
Nurses)
- [Pre-workgroup meeting comment] Measures of patient fall rates have
been under consideration by the MAP on more than one occasion. AMRPA remains
concerned that such measures are not appropriate for several reasons. First,
by focusing on fall rates it is possible providers will avoid patients they
deem at risk at falls in an effort to avoid a negative quality score. Second,
in some instances it is appropriate to facilitate a fall for patients to
demonstrate how to fall safely. Unfortunately the measure is unclear if it
accounts for the important distinction between assisted and unassisted falls.
Additionally weíd like to see clarification on the definition of a fall (for
example clarity that practicing a floor transfer, where a therapist has a
patient learn how to get to the floor and rise from the floor, would not
constitute a fall). Perhaps what is more important to measure than the fall
is the outcome of the fall; specifically whether there was an injury as a
result of the fall. We also have concerns associated with the risk adjustment
for this measure because it applies to a variety of settings and the
circumstances surrounding a fall can vary dramatically by setting. While many
of our members are already collecting this data, we cannot support its
inclusion at this time because of the flaws we have identified with its
inclusion of assisted falls and its failure to focus on the result of the fall
as opposed to the fall itself. (Submitted by: American Medical Rehabilitation
Providers Association)
- [Pre-workgroup meeting comment] While FAH agrees that a standard
fall measure would be beneficial for inpatient rehabilitation there currently
is no industry standard definition for fall or falls with injury. We strongly
disagree that ìall fallsî is an appropriate measure for inpatient
rehabilitation, particularly since the measure includes assisted falls. Given
the nature of rehabilitation, patients are encouraged to be mobile and
independent and falls are an unintended and even unavoidable consequence.
Furthermore, the inevitability of falls is evidenced by rehabilitation
hospitalsí occasional need to ìteach patients how to fall.î These kinds of
education programs realize that falls may be difficult to avoid completely,
but there is benefit in teach patients how to fall to minimize risk and injury
to themselves. Given these circumstances, we believe a ìfalls with injuryî
measure would be more relevant to the inpatient rehabilitation setting. A
measure similar to NQF Measure #0674 proposed in the ìMedicare Program;
Inpatient Rehabilitation Facility Prospective Payment System for Federal
Fiscal Year 2015î rule would be a better choice. NQF#0674 is currently
specified for the long-term setting but likely could be re-specified for use
in the short-stay environments. If the measure is re-specified and tested in
the short-stay setting it may be more appropriate than the proposed MUC
patient fall rate E0141.(Submitted by: Federation of American
Hospitals)
- [Pre-workgroup meeting comment] I agree with a standard fall rate
measure however, there needs to be consnesus on the definition of the term
fall and for inpatient rehab hospitals falls wit injuries would be a better
quality measure.(Submitted by: HealthSouth)
- [Pre-workgroup meeting comment] HealthSouth agrees that a standard
fall measure would be beneficial for inpatient rehabilitation since currently
there is no industry standard definition for fall or falls with injury.
However, we disagree that ìall fallsî is an appropriate measure for inpatient
rehabilitation, particularly a measure that includes assisted falls. Given
the nature of rehabilitation, patients are encouraged to be mobile and
independent and falls are an unintended and even unavoidable consequence.
Furthermore, the inevitability of falls is evidenced by rehabilitation
hospitalsí occasional need to ìteach patients how to fall.î These kinds of
education programs realize that falls may be difficult to avoid completely,
but there is benefit in teach patients how to fall to minimize risk and injury
to themselves. Given these circumstances, we believe a ìfalls with injuryî
measure may be more relevant to the inpatient rehabilitation setting, similar
to the NQF Measure #0674 proposed in the ìMedicare Program; Inpatient
Rehabilitation Facility Prospective Payment System for Federal Fiscal Year
2015î rule. While this measure is only approved for use in long-term
settings, a modification of this measure for use in short-stay environments
may be more appropriate than the proposed MUC patient fall rate E0141. We
also believe appropriate risk-adjustment will be necessary to validate this
measure. Additionally, given this measure is being proposed or already in
place for Hospital Inpatient Quality Reporting, Inpatient Rehabilitation
Facility Quality Reporting, and Long-Term Care Hospital Quality Reporting, we
would support this measure this or a similar measure to also be proposed for
Skilled Nursing Facilities. (Submitted by: HealthSouth
Corporation)
- [Pre-workgroup meeting comment] Any fall measure in rehabilitation
should be related to "falls with injury." The nature of rehabiltiation
related to falls is unique compared to other settings - particularly that
patients are being encouraged to be mobile (likely, for the first time since a
traumatic clinical event) and "assisted falls" are commonplace. Incuding
these falls would likely mean hospitals don't report accurately. Falls with
injury is a far more relevant way to capture falls in the rehabilitation
setting.(Submitted by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] modify to falls with injury and
allow for risk-adjustment(Submitted by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] As Certified Rehabilitation RN
with over 20 years of practice in inpatient rehabilitation nursing and
quality, I strongly agree that falls are a significant safety concern for our
population. This measure however, focuses on all falls which could diminish
the effectiveness of data analysis. We should focus on falls with injury to
improve safety in the rehab population. I do not support, as some of my
colleagues do, that falls are inevitable, but I do think it is rare that a
rehabilitation setting will expereince very many months without some kind of
fall. We watch our patients learn to transfer from a bed to a chair or the
toilet, testing their new skills and strength gained in physical therapy. We
intervene when they need our help and sometimes, must lower them to the floor.
That is the safest thing to do in many cases. If we never let patients
practice ambulation and transfers, they and their families will not be
prepared to go home. The ability to prevent an injury when they know they are
going down is key to success at home. (Submitted by: HealthSouth
Corproation)
| (Program: Long-Term Care Hospitals Quality Reporting Program; MUC
ID: E0141) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
| (Program: Medicare Shared Savings
Program; MUC ID: E0171) |
- We thank the Measure Applications Partnership Coordinating Committee for
the opportunity to provide comments on their 2014-2015 Preliminary
Recommendations for measures under consideration. We would like to express
our support for measure E0171 as it would add value to the program measure set
and has the potential to improve patient outcomes through addressing the unmet
burden of Clostridium difficile infections (CDI) in long-term care (LTC)
facilities. C. difficile is the most common bacterial cause of infectious
diarrhea in LTC facilities and LTC patients with CDI had shorter times to
hospitalization and shorter time to mortality compared to LTC patients without
CDI. 1,2 The Agency for Healthcare Research and Quality Healthcare and Cost
Utilization Project estimated that 41.5% of hospitalized patients with CDI
were discharged to LTC, with 49% readmitted within 90 days.3 It is for these
reasons that we support measure E0171 as it encourages accountability that may
improve patient outcomes by addressing care coordination and avoidable
hospital admissions and readmissions due to recurrent infections like C.
difficile. References: 1. Simor AE. Diagnosis, management, and prevention of
Clostridium difficile infection in long-term care facilities: a review.
Journal of the American Geriatrics Society 2010;58:1556-64. 2. Friedman HS,
Navaratnam P, Reardon G, High KP, Strauss ME. A retrospective analysis of
clinical characteristics, hospitalization, and functional outcomes in
residents with and without Clostridium difficile infection in US long-term
care facilities. Current medical research and opinion 2014;30:1121-30.
3. Elixhauser A, Steiner C, Gould C. Readmissions following Hospitalizations
with Clostridium difficile infections, 2009. HCUP Statistical Brief #145
2012.(Submitted by: Merck, Sharp and Dohme, Inc.)
- TAHCH supports alignment with the Home Health Quality reporting program.
(Submitted by: Texas Association for Home Care & Hospice )
- VNAA supports the importance of preventing hospitalizations from home
health agencies. The 60-day hospitalization proposed measure for the Medicare
Shared Savings Program takes on a different purpose from a pay-for-reporting
measure on Home Health Compare to a measure for a MSSP that has financial
implications. Several issues for this new use of the measure: In the MSSP
models, home health agencies are part of data sharing agreements and
agreements for shared quality goals. The sharing of key items and codes
across each electronic health records will be essential for organizations to
be able to understand each patientís particular status and needs such as the
availability of a caregiver. While this will improve coordination of care,
organizations will need time to accelerate sharing of essential patient
level-data among all entities involved in care. Additionally, VNAA is concern
about the 60-day time frame for this measure. Most patients are not active in
home health for 60 days instead it is approximately 45 days, so we recommend
that CMS consider a shorter hospitalization time frame such as the new 30-day
readmission time frame. This is congruent with the SNF measure currently in
place for the MSSPs ACOS. Secondly, adequate risk adjustment for the
claims-based measure is critical. Ability to connect the OASIS data set to the
claims data would allow for capture of critical patient socio-demographic and
functional status that would create a level field for all agencies including
those who care for the most deconditioned and vulnerable patients.
(Submitted by: VNAA)
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0202)
|
- ? The American Association of Colleges of Nursing supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
falls and falls with injury and requests MAP report corrections ? The MAP
report should be amended to reflect the Hospital WG vote accurately to reflect
the following o The only condition identified by the MAP Hospital WG by the
majority vote was NQF-endorsement for hospital-level reporting o CMS noted
that CMS and AHRQ do not consider the measures as duplicative to any existing
measure (no harmonization issue exists) o The Hospital WG did not identify
under-reporting related to falls with injury o Under-reporting was not an
agreed upon condition for the falls rate measure (Submitted by: American
Association of Colleges of Nursing)
- The American Association of Nurse Anesthetists supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
falls and falls with injury. Both these outcome measures are critical to
improving patient safety. They fill a serious gap in falls measures on
Hospital Compare that consumer, purchasers, ANA and other stakeholders have
noted. The MAP report should be amended to reflect the broad Hospital WG
majority support (73%) vote for ìconditional supportî for these measures. As
outcomes measures, these measures are superior to claims based measures
because they are not subject to known coding issues (server under-reporting
with claims driven metrics), allow for timely reporting, and are clinically
enriched (e.g., clinical assessment data used). There are no harmonization
issues with other measures per CMS and AHRQ and fill a gap. (Submitted by:
American Association of Nurse Anesthetists)
- ANA supports the Hospital Workgroup (WG) vote of ìconditional supportî of
the NQF-endorsed measures falls (E 0141 and falls with injury and requests MAP
Draft Voting Report corrections: ? The MAP report should be amended to
accurately reflect the Hospital WG vote: o The only condition identified by
the MAP Hospital WG by the majority vote was NQF-endorsement for
hospital-level reporting. o CMS noted that neither CMS nor AHRQ consider the
measures as duplicative to any existing measure (no harmonization issue
exists). o The Hospital WG did not identify under-reporting related to falls
with injury. Additionally, the majority of HG WG members supported both
measures and are not concerned about issues with under-reporting. Rather,
they support a safety culture with reporting of both of these reliable and
valid measure endorsed by NQF. o Specifically, under-reporting was not an
agreed upon condition for the falls rate or the falls with injury measures. o
CMS and AHRQ do not see a harmonization issue with the
exisitng AHRQ PSI measure with either ANA falls mesaures (falls and falls with
injury) o Specifically, harmonization was not a condition
that was agreed upon or voted upon by the Hospital WG for either the ANA falls
or falls with injury measures(Submitted by: American Nurses Association
)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- The Oncology Nursing Society supports the Hospital Workgroup vote of
"conditional support" of the NQF-endorsed measures falls and falls with injury
and requests that MAP include the following corrections: 1) the only condition
identified by the Hospital Workgroup by majority vote was NQF-endorsement for
hospital level reporting, 2) CMS noted that CMS and AHRQ do not consider the
measures as duplicative to any existing measures (no harmonization issue
exists), 3) the Hospital workgroup did not identify under-reporting related to
falls with injury, 4) under-reporting was not an agreed upon condition for
falls rate measures(Submitted by: Oncology Nursing Society)
- Would like the option to push data from NDNQI to CMS rather than
duplicative reporting. (Submitted by: Park Nicollet Methodist
Hospital)
- Press Ganey supports this measure as a very important part of measuring
major hospital-acquired conditions. (Submitted by: Press Ganey
Associates)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. The proposed measure is an American Nurses
Association (ANA) developed nursing-sensitive safety measure developed to help
close the gap on the underreporting of falls with injury in the current AHRQ
Patient Safety Indicator measure which only includes post-surgical hip
fractures which is a small portion of the prevalent injuries from falls in
hospitals. To more accurately capture falls with injury in hospitals, SEIU
supports this measure which incorporates a broader definition of falls. SEIU
supports approval of this measure and the Patient Fall Rate Measure proposed
as gaps persist in capturing and reporting patient falls. Taken together,
these measures work in tandem for an effective falls and falls with injury
reduction program. As Hospital MAP work group members noted, falls are a
common adverse event in hospitals, with estimates of between 2-5 falls per
1,000 patient days. This is an important area for measurement as about 30% of
falls result in injury, disability, or death. Furthermore utilization of this
measure will help the NQF Hospital MAP achieve its objective of pursuing high
value performance measures in hospital accountability programs to get
consumers the information they need to make informed decisions about their
health care. (Submitted by: Service Employees International
Union)
- SHM agrees with the MAP recommendation for conditional support, but notes
that there may be issues with data collection on falls and a risk of
under-reporting. This may inadvertently penalize institutions that have
prioritized accurate reporting and raises questions about how improvement can
be tracked.(Submitted by: Society of Hospital Medicine)
- WOCN supports the workgroup vote of conditional support of the NQF
measures (Submitted by: Wound Ostomy and Continence Nurses)
- The American Association of Neuroscience Nurses (AANN) supports the
Hospital Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed
measures falls and falls with injury and requests MAP report corrections. The
MAP report should be amended to reflect the Hospital WG vote accurately to
reflect the following. o The only condition identified by the MAP Hospital WG
by the majority vote was NQF-endorsement for hospital-level reporting o CMS
noted that CMS and AHRQ do not consider the measures as duplicative to any
existing measure (no harmonization issue exists) o The Hospital WG did not
identify under-reporting related to falls with injury o Under-reporting was
not an agreed upon condition for the falls rate measure (Submitted by:
American Association of Neuroscience Nurses (AANN))
- AGS notes that there is limited data to support any particular fall
prevention strategy in hospitals. Many frail elders are physiologic fallers ñ
and thus would be expected to experience some falls rate while hospitalized.
The strategies for these patients are safe, progressive, and aggressive
mobility programs. In addition, as the outcome of interest is injurious falls,
the use of an all falls measure is of questionable value, particularly as
reporting of falls is likely to be variable. AGS is concerned that mandating
hospital reporting would lead to under-reporting. Perhaps a better measure of
quality would be hospitalsí compliance with falls risk assessment (e.g. Morse,
Hendrich) and implementation of appropriate preventative measures, such as
eliminating tethers (iv lines, telemetry lines, urinary catheters), bed/chair
alarms, working call bells within patientsí reach, de-cluttering patientsí
rooms. (Submitted by: American Geriatrics Society)
- ? The ANA/NDNA supports the Hospital Workgroup (WG) vote of ìconditional
supportî of the NQF-endorsed measures falls and falls with injury and requests
MAP report corrections ? The MAP report should be amended to reflect the
Hospital WG vote accurately to reflect the following o The only condition
identified by the MAP Hospital WG by the majority vote was NQF-endorsement for
hospital-level reporting o CMS noted that CMS and AHRQ do not consider the
measures as duplicative to any existing measure (no harmonization issue
exists) o The Hospital WG did not identify under-reporting related to falls
with injury o Under-reporting was not an agreed upon condition for the falls
rate measure (Submitted by: ANA/NDNA)
- AORN supports the Hospital Workgroup vote of conditional support of the
NQF-endorsed measures Falls and Falls with Injury and requests MAP report
corrections. The MAP report should be amended to reflect the Hospital
Workgroup vote: The only condition identified by the MAP Hospital Workgroup by
the majority vote was NQF-endorsement for hospital-level reporting. CMS noted
that CMS and AHRQ do not consider the measures as duplicative to any existing
measure (no harmonization issue exists). The Hospital Workgroup did not
identify under-reporting related to falls with injury. Under-reporting was
not an agreed-upon condition for the Falls rate measure.(Submitted by: AORN -
Association of periOperative Registered Nurses)
- [Pre-workgroup meeting comment] The definitions of injury levels
would have to be very specific for standardized reporting across all
hospitals. Most hospitals are already participating in a patient safety
organization (PSO). (Submitted by: Vidant Health)
| (Program: Inpatient
Quality Reporting Program ; MUC ID: E0204) |
- ? The American Association of Colleges of Nursing supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
nurse staffing and skill mix and requests MAP report corrections ? The MAP
report should be amended to accurately reflect the MAP Hospital WG vote that
identified only one ìconditionî, NQF endorsement at the hospital-level
reporting, be met ï Majority of the workgroup (73% vote) for ìconditional
supportî only related to one condition, NQF-endorsement for hospital-level
reporting ï Other conditions listed in the MAP report were not agreed upon by
the Hospital Workgroup during voting majority, are incorrectly listed as
conditions to be met and should be removed (Submitted by: American Association
of Colleges of Nursing)
- The American Association of Nurse Anesthetists supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
nurse staffing and skill mix and requests MAP report corrections. The MAP
report should be amended to accurately reflect the MAP Hospital WG vote that
identified only one ìconditionî, NQF endorsement at the hospital-level
reporting, be met. The majority of the workgroup (73%) voted for ìconditional
supportî only related to one condition, NQF-endorsement for hospital-level
reporting. Other conditions listed in the MAP report that were not agreed upon
by the majority of the Hospital Workgroup during voting, are incorrectly
listed as conditions to be met and should be removed.(Submitted by: American
Association of Nurse Anesthetists)
- ANA supports the Hospital Workgroup (WG) vote of ìconditional supportî of
the NQF-endorsed measures nurse staffing (e0205) and skill mix (E204) and
requests MAP Voting Draft report corrections. ï The MAP report should be
amended to accurately reflect the MAP Hospital WG vote that identified only
one ìconditionî be met, NQF endorsement at the hospital-level reporting.
ï Majority of the workgroup (71%) voted for ìconditional supportî only
related to only one condition, NQF-endorsement for hospital-level reporting.
ï Other conditions listed in the MAP report were not agreed by the Hospital
Workgroup and are incorrectly listed as conditions to be met. These should be
removed. Additionally, the report should the broad support for these measures
by the Hospital WG including the the majority of the Hospital WG. Multiple
stakehodlers noted the importamce of these measures for public reporting and
safety including the Chair and Co-chairs. (Submitted by: American Nurses
Association )
- AORN supports the Hospital Workgroup's vote of conditional support of the
NQF-endorsed measures nurse staffing and skill mix, and requests MAP report
corrections. The MAP report should be amended to accurately reflect the MAP
Hospial WG vote that identified only one "condition," NQF endorsement at the
hospital-level reporting, be met. The majority of the WG -73% - voted for
conditional support only related to one condition- NQF endorsement for
hospital-level reporting. Other conditions listed in the MAP report were not
agreed upon by the Hospital WG during voting majority, and are incorrectly
listed as conditions to be met, and should be removed.(Submitted by: AORN -
Association of periOperative Registered Nurses)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- The Oncology Nursing Society supports the Hospital Workgroup vote of
"conditional support" of the NQF-endorsed measures of nurse staffing and skill
mix and requests that MAP Report be amended to accurately reflect the
Workgroup vote that identified only one "condition", NQF endorsement at the
hospital level reporting be met. The majority of the workgroup (73%) voted for
one "condition" to be reported. Other conditions listed in the MAP Report
were not agreed upon by the Hospital Workgroup during voting and are
incorrectly listed as conditions to be met and should be removed.(Submitted
by: Oncology Nursing Society)
- Would like the option to push data from NDNQI to CMS rather than
duplicative reporting. (Submitted by: Park Nicollet Methodist
Hospital)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. SEIU has a unique and vested interest in all
quality measures that support the workforce responsible for delivering care
due to the knowledge we have cultivated representing over 1 million healthcare
workers. A hospitalís ability to provide high-quality care depends largely on
its frontline personnel. The proposed measure is an American Nurses
Association (ANA) developed nursing-sensitive safety measure SEIU supports
approval of this measure and the Nursing Hours Per Patient Day Measure
proposed because these two measures are sensitive to frontline workers who
play a critical role in delivering quality care. Furthermore, workforce is
one of nine action drivers to reach national safety goals identified in the
National Quality Strategy. SEIU supports this measure because research shows
that when a hospital focuses on optimizing the nursing skill mix around both
patient needs and total cost, it is better positioned to deliver safe,
effective, high-quality care in a fiscally responsible manner. Nurses make up
the highest proportion of team members and robust evidence over time has
demonstrated the importance of nurse staffing and skill mix to patient safety
and the reduction of adverse events. Currently there exists wide variance in
nurse staffing across U.S. hospitals and the development of this measure by
the American Nurses Association (ANA) should help minimize this variance.
SEIU would like to see this measure fully supported as nurses are indeed a
service line essential to safety. (Submitted by: Service Employees
International Union)
- WOCN supports the workgroup vote of conditional support of the NQF
measures(Submitted by: Wound Ostomy and Continence Nurses)
- The American Association of Neuroscience Nurses supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
nurse staffing and skill mix and requests MAP report corrections. The MAP
report should be amended to accurately reflect the MAP Hospital WG vote that
identified only one ìconditionî, NQF endorsement at the hospital-level
reporting, be met . ï Majority of the workgroup (73% vote) for ìconditional
supportî only related to one condition, NQF-endorsement for hospital-level
reporting. ï Other conditions listed in the MAP report were not agreed upon by
the Hospital Workgroup during voting majority, are incorrectly listed as
conditions to be met and should be removed.(Submitted by: American Association
of Neuroscience Nurses (AANN))
- GNYHA does not support this measure in the Inpatient Quality Reporting
(IQR) Program. Given the significant regional variation in how staffing plans
are developed, skill mix cannot be fairly or adequately measured across
hospitals. For the same reason, the measure would be misinterpreted and
misused as a public measure by consumers and others. However, while GNYHA does
not support this measure for IQR, we believe it is a very important measure to
help hospitals address nursing hours and skill mix when evaluating internal
staffing plans.(Submitted by: Greater New York Hospital
Association)
- Press Ganey supports this measure. Years of research have shown this
measure has a strong correlation with many important measures of patient
safety.(Submitted by: Press Ganey Associates)
- ? The ANA/NDNA supports the Hospital Workgroup (WG) vote of ìconditional
supportî of the NQF-endorsed measures nurse staffing and skill mix and
requests MAP report corrections ? The MAP report should be amended to
accurately reflect the MAP Hospital WG vote that identified only one
ìconditionî, NQF endorsement at the hospital-level reporting, be met
ï Majority of the workgroup (73% vote) for ìconditional supportî only related
to one condition, NQF-endorsement for hospital-level reporting ï Other
conditions listed in the MAP report were not agreed upon by the Hospital
Workgroup during voting majority, are incorrectly listed as conditions to be
met and should be removed (Submitted by: NDNA/ANA)
- The Academy of Medical-Surgical Nurses supports the Hospital Workgroup
vote of conditional support of the NQF endorsed measures for nurse staffing
and skill mix. The MAP report should be amended to reflect the MAP hospital WG
vote that identified only one condition, NQF endorsement at the hospital
-level reporting be met - then other conditions were not agreed upon and
should be removed.(Submitted by: Academy of Medical Surgical
Nurses)
- AORN supports the Hospital Workgroup vote of conditional support of the
NQF-endorsed measures nurse staffing and skill mix. These are high impact
safety measures. Two decades of research shows that better nurse staffing and
skill mix is associated with lower patient harm rates (e.g., death, falls,
infections, pressure ulcers, etc.) Wide variance in nurse staffing continues,
particularly in medical surgical units. The MAP Hospital Workgroup
discussion should be reflected accurately by amending the MAP draft report.
The NQF MAP suggested vote of "Do not support" was rejected by the Workgroup.
The MAP report should be amended to reflect the broad Hospital Workgroup
support for these measures. Workgroup members noted that these nursing
measures are essential to improve patient safety and inform consumers,
purchasers and other stakeholders. (Submitted by: AORN - Association of
periOperative Registered Nurses)
- [Pre-workgroup meeting comment] Need to assess retention/turnover.
A tool to determine why nurses leave. Patterns to determine deficient areas
and how accountability occurs. Assess years of experience of nurses(Submitted
by: self)
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0205)
|
- The American Association of Nurse Anesthetists supports the Hospital
Workgroup (WG) vote of ìconditional supportî of the NQF-endorsed measures
nurse staffing and skill mix and requests MAP report corrections. The MAP
report should be amended to accurately reflect the MAP Hospital WG vote that
identified only one ìconditionî, NQF endorsement at the hospital-level
reporting, be met. The majority of the workgroup (73%) voted for ìconditional
supportî only related to one condition, NQF-endorsement for hospital-level
reporting. Other conditions listed in the MAP report that were not agreed upon
by the majority of the Hospital Workgroup during voting, are incorrectly
listed as conditions to be met and should be removed.(Submitted by: American
Association of Nurse Anesthetists)
- ANA supports the Hospital Workgroup (WG) vote of ìconditional supportî of
the NQF-endorsed measures nurse staffing (e0205) and skill mix (E204) and
requests MAP Voting Draft report corrections. ? The MAP report should be
amended to accurately reflect the MAP Hospital WG vote that identified only
one ìconditionî be met, NQF endorsement at the hospital-level reporting.
ï Majority of the workgroup (71%) voted for ìconditional supportî only
related to only one condition, NQF-endorsement for hospital-level reporting.
ï Other conditions listed in the MAP report were not agreed by the Hospital
Workgroup and are incorrectly listed as conditions to be met. These should be
removed. Additionally, the report should the broad support for these measures
by the Hospital WG including the the majority of the Hospital WG. Multiple
stakehodlers noted the importamce of these measures for public reporting and
safety including the Chair and Co-chairs.(Submitted by: American Nurses
Association )
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- Would like the option to push data from NDNQI to CMS rather than
duplicative reporting. (Submitted by: Park Nicollet Methodist
Hospital)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. SEIU has a unique and vested interest in all
quality measures that support the workforce responsible for delivering care
due to the knowledge we have cultivated representing over 1 million healthcare
workers. A hospitalís ability to provide high-quality care depends largely on
its frontline personnel. The proposed measure is an American Nurses
Association (ANA) developed nursing-sensitive safety measure and SEIU supports
approval of this measure and the Nursing Skill Mix Measure proposed because
these two measures are sensitive to frontline workers who play a critical role
in delivering quality care. Furthermore, workforce is one of nine action
drivers to reach national safety goals identified in the National Quality
Strategy. One example from the robust academic literature on this issue is
the The International Journal of Nursing Studies released in 2010 titled The
impact of the nursing hours per patient day (NHPPD) staffing method on patient
outcomes: a retrospective analysis of patient and staffing data - the study
found significant decreases in the rates of nine nursing-sensitive outcomes
when examining hospital-level data following implementation of NHPPD method;
mortality, central nervous system complications, pressure ulcers, deep vein
thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed shock/cardiac
arrest, pneumonia and average length of stay. Nurses make up the highest
proportion of team members and robust evidence over time has demonstrated the
importance of nurse staffing and skill mix to patient safety and the reduction
of adverse events. Currently there exists wide variance in nurse staffing
across U.S. hospitals and the development of this measure by the American
Nurses Association (ANA) should help minimize this variance. SEIU would
like to see this measure fully supported as nurses are indeed a service line
essential to safety. (Submitted by: Service Employees International
Union)
- GNYHA does not support this measure for the IQR program. Given the
significant regional variation in how staffing plans are developed, skill mix
cannot be fairly or adequately measured across hospitals. For the same
reason, the measure would be misinterpreted and misused as a public measure by
consumers and others. However, while GNYHA does not support of this measure
for IQR, we believe it is a very important measure to help hospitals address
hours and skill mix when evaluating internal staffing plans.(Submitted by:
Greater New York Hospital Association)
- Press Ganey supports this measures. Years of research has shown this
measure to be strongly correlated to many other important measures of patient
safety. (Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] need to assess nurses working more
than 8 hours, more than 12 hours, more than 16 hours in a 24 hour period. To
include call coverage. Number of hours worked last 90 days. refer to studies
on nursing fatigue and patient safety.(Submitted by: self)
| (Program: PPS-Exempt Cancer Hospital Quality
Reporting Program ; MUC ID: E0219) |
- Position: Adopt with modifications, as described below. Relevance: The
Cancer Centers treat patients with AJCC stage I, II, or III breast cancers.
Many of these patients are appropriate candidates for radiation therapy
following breast conservation surgery. The ADCC recommends that the measure
steward adopt additional exclusion criteria before this measure is adopted for
the PCHQR. Additionally, we recommend that appropriate attention be given to
facilities with patient populations that deviate from the tested/studied
cohorts. Adjustments should be made to the specifications in order to provide
accurate representations of the measured value. Usability: The ADCC
appreciates that this measure promotes appropriate management and reduces
recurrence among patients diagnosed with AJCC stage I, II, or III breast
cancer. Most ADCC facilities reported ìtopped outî performance in the 90%+
range, with several Cancer Centers reporting rates at 100%, demonstrating that
the measure offers little additional value for the PCHQR. When these measures
were originally collected by the Cancer Centers, improved concordance rates
were observed. Of note, the Cancer Centers continue to closely follow our
performance on this measure to ensure continued adherence to the
evidence-based guidelines. However, most have seen maximum improvement and do
not see anticipate further benefit from collection as part of the PCHQR.
Thus, CMS may find it beneficial to adopt this measure for community-based
oncology care where cancer care delivery is not routinely integrated.
Adoption of this measure for the PCHQR for purposes of establishing benchmarks
for the IQR program is not an efficient use of PCH or CMS resources. No other
measures in the PCHQR program address this aspect of patient care.
Feasibility: No additional reporting burden is anticipated in continued
reporting, as this measure is currently collected via the ACoS Rapid Quality
Reporting System (RQRS). (Submitted by: Alliance of Dedicated Cancer
Centers)
- The MAP Hospital Workgroupís provisional recommendation is ìconditional
supportî for the inclusion of this measure in the PPS-Exempt Cancer Hospital
Quality Reporting. However, the ACS strongly recommends full ìsupportî of this
NQF-endorsed measure. Since 2007, the National Cancer Data Base has reported
facility-level compliance with this measure to approximately 1500 Commission
on Cancer (CoC) accredited programs. If it would improve the expediency of
providing this valuable information to the public, we recommend progressing
inclusion of this measure in the PPS-Exempt Cancer Hospital Quality Reporting
program and the IQR program independently. Though compliance with this measure
is generally high, it is clinically significant enough to remain an important
benchmark for public reporting among all types of hospitals providing cancer
care as it is critical to impact the outcome of care. This measure is
currently being reported publicly through the voluntary Pennsylvania Health
Care Quality Alliance (PHCQA), http://www.phcqa.org/. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] Position: We support the direction
of this measure but believe exclusion criteria needs to be both clarified and
evaluated for comprehensiveness before application of this measure to the
PCHQR program. The ADCC recommends that the measure steward be contacted with
our concerns to make amenable edits. Would addition of the measure add value
to the program measure set? Most ADCC facilities reported ìtopped outî
performance in the 90%+ range, with several centers reporting rates at 100%.
Therefore, this measure offers little value for the PCHQR program. What is the
measureís potential to improve patient outcomes? This measure ensures that
patients diagnosed with AJCC stage I II or III breast cancer are appropriately
managed to reduce recurrence of disease. However, as noted above, our
centers have high levels of compliance. Would use of the measure create undue
data collection or reporting burden? No additional burden is anticipated for
collection of this measure. Is there a better measure available or does a
measure already in the program set address a particular program objective? No.
(Submitted by: Alliance of Dedicated Cancer Centers)
| (Program: PPS-Exempt Cancer Hospital Quality Reporting Program ;
MUC ID: E0221) |
- Position: Do not adopt this measure. Relevance: The Cancer Centers treat
patients with AJCC stage 0, I, II, or III breast cancers. Many of these
patients are appropriate candidates for needle biopsy before surgical
excision. However, the currently-endorsed measure is missing important
exclusions. For example, malignant lesions diagnosed by needle biopsy that
require excisional biopsy are not addressed. The measure should be revised to
exclude patients that fit this scenario. Additionally, when data collection
for this particular element was implemented approximately 12-15 years ago,
ACoS originally stated that, if a core biopsy led to the complete removal of a
tumor, this would NOT be gathered in the biopsy section, but instead coded as
cancer-directed surgery. A few years later, ACoS revised the FORDS manual,
which directs cancer registry staff in submitting data for this measure, and
advised to always document the biopsy in the biopsy section, whether the
entire tumor was removed or not. This particular data element remains
ambiguous to this day, with much discussion and differences of opinion among
the cancer registry profession. For the most part, clarifications have removed
much of the ambiguity so that the confidence level for the data presented and
represented by this measure is higher than in previous years. CMS should
postpone adoption of this measure until further data validation is completed
by each registry to ensure that no false-negatives exist. Of note, during the
early commenting period, the ADCC requested changes to the measure exclusion
criteria, some of which are reflected in recent measures changes that were
submitted to the NQF as part of annual measure maintenance. The ADCC requests
that detailed measure specifications be posted to the NQF Quality Positioning
System to facilitate more detailed measure review based on these changes. The
ADCC recommends that the measure steward adopt additional exclusion criteria,
as described herein, before this measure is adopted for the PCHQR.
Usability: The ADCC appreciates that this measure promotes appropriate
diagnostic tests among patients diagnosed with AJCC stage 0, I, II, or III
breast cancer. This measure is not yet ìtopped outî for the Cancer Centers.
However, due to the measure specification issues described above, this measure
lacks a clear relationship to improving patient outcomes. Thus, the ADCC
requests that additional exclusions be applied by the steward to address our
noted concerns. For example, some patients undergo an excisional biopsy to
establish a cancer diagnosis at an outside institution and subsequently go to
a Cancer Center for definitive care/surgery. As the measure is written, these
patients would be considered discordant, even though a Cancer Center did not
perform the initial excisional biopsy. We reiterate our request that the
measure be revised to exclude patients that fit this scenario. No other
measures in the PCHQR program address this aspect of patient care.
Feasibility: This measure is not currently part of RQRS, and it is not clear
when/if this measure will be added to RQRS. Therefore, feasibility will be an
issue as RQRS is the current reporting mechanism for the currently-adopted
ACoS measures. Data for a similar, albeit different, measure (ìImage or
palpation-guided needle biopsy (core or FNA) is performed to establish
diagnosis of breast cancerî) are collected annually via the ACoS National
Cancer Data Base (NCDB) and are included in the Cancer Program Practice
Profile Reports (CP3R) reports from ACoS. However, the timeliness of the CP3R
reports is not conducive to meeting the CMS reporting timelines for the
currently-adopted ACoS measures. Additionally, the measure includes a broader
denominator population than the existing breast cancer measures reported via
RQRS (0559-Combination chemotherapy is considered or administered within 4
months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage
IB - III hormone receptor negative breast cancer and 0220-Adjuvant hormonal
therapy). Therefore, including this measure would likely require a change in
the current RQRS case finding processes at the Cancer Centers and,
potentially, IT changes where case finding is automated. Moreover, for some
Cancer Centers, the RQRS measures require concurrent and duplicative
abstraction because of the separate NCDB abstraction and submission process.
Therefore, there may be additional resource requirements for some Cancer
Centers. (Submitted by: Alliance of Dedicated Cancer Centers)
- The MAP Hospital Workgroupís provisional recommendation is ìconditional
supportî for the inclusion of this measure in the PPS-Exempt Cancer Hospital
Quality Reporting program. However, the ACS strongly recommends full ìsupportî
of this measure. Measure E0221 was initially reported by the ACS CoC in 2013.
It has wide applicability for public reporting for all hospitals that care for
cancer patients. ACS submitted changes to the NQF during the annual update
of this measure to improve the accuracy of reported compliance rates. The
measure description was updated to: ìImage or palpation guided needle biopsy
(core or FNA) of the primary site is performed to establish the diagnosis of
breast cancer.î Important changes submitted to this measure are the removal
of the requirement of receipt of surgical treatment, exclusion of metastatic
disease, and exclusions of additional clinically valid reasons a patient will
not receive a needle biopsy for the diagnosis of breast cancer that are not
captured through Facility Oncology Registry Data Standards (FORDS). These
exclusions include: ï Patient refused biopsy ï Patient medically unable to
hold position for image guided biopsy ï Patient requires sub areolar excision
for nipple discharge ï Lesion too superficial ï Breast too small ï Lesion
inaccessible by needle biopsy ï Cancer found in prophylactic mastectomy
ï Benign high risk lesions diagnosed by needle biopsy, requiring excisional
biopsy ï Discordant biopsy results compared to suspicious imaging (Submitted
by: The American College of Surgeons)
- [Pre-workgroup meeting comment] Position: This measure assesses
adherence to an important standard of care, but we do not support adoption at
this time because the exclusion criteria need to be both clarified and
evaluated for comprehensiveness. We recommend that CMS delay consideration of
this measure for the PCHQR program until the measure steward has revised the
measure to address these concerns. Would addition of the measure add value
to the program measure set? Current exclusions for the measure include;
ï Patient refused biopsy; ï Patient medically unable to hold position for
image-guided biopsy; ï Patient requires subareolar excision for nipple
discharge; ï Lesion is too superficial; ï Breast is too small; ï Lesion
inaccessible by needle biopsy; ï Cancer round in prophylactic mastectomy; and
ï Benign high risk lesions diagnosed by needle biopsy, requiring excisional
biopsy. The centers believe that additional exclusions should be explored
before applying this measure to the PCHQR program. For example, some patients
undergo an excisional biopsy to establish a cancer diagnosis at an outside
institution and subsequently go to an ADCC facility for definitive
care/surgery. As the measure is written, these patients would be considered
discordant, even though the ADCC centers did not perform the initial
excisional biopsy. The measure should be revised to exclude patients that fit
this scenario. Otherwise, this would be a potentially discriminatory metric
for ADCC centers with a high volume of external referrals where the diagnostic
biopsy is not necessarily by core needle biopsy. Additionally, when data
collection for this particular element was implemented approximately 12-15
years ago, the American College of Surgeons (ACoS) originally stated that, if
a core biopsy led to the complete removal of a tumor, this would NOT be
gathered in the biopsy section but instead coded as cancer-directed surgery.
A few years later, the College revised the FORDS manualówhich directs Cancer
Registry staff in submitting data for this measure, óadvising to always
document the biopsy in the biopsy section whether the entire tumor was removed
or not. This particular data element remains ambiguous to this day, with
much discussion and differences of opinion among the Cancer Registry
profession. For the most part, clarifications have removed much of the
ambiguity so that the confidence level for the data presented and represented
by this measure is higher than in previous years. CMS should postpone
adoption of this measure until further data validation is completed by each
registry to ensure that no false-negatives exist. What is the measureís
potential to improve patient outcomes? This measure is not yet ìtopped outî
for the ADCC centers. However, due to the measure specification issues
described above, this measure lacks a clear relationship to improving patient
outcomes. Would use of the measure create undue data collection or reporting
burden? This measure is not currently part of RQRS, and it is not clear
when/if this measure will be added to RQRS. Therefore, feasibility will be an
issue based on the current reporting structure via RQRS. Data for a similar,
albeit different, measure (ìImage or palpation-guided needle biopsy (core or
FNA) is performed to establish diagnosis of breast cancerî) are collected
annually via the ACoS National Cancer Data Base (NCDB) and are included in the
Cancer Program Practice Profile Reports (CP3R) reports from ACoS. However,
the timeliness of the CP3R reports is not conducive to meeting the CMS
reporting timelines for the currently adopted ACoS measures. Additionally,
the measure includes a broader denominator population than the existing breast
cancer measures reported via RQRS (#0559 and 0220). Therefore, including this
measure would likely require a change in the current RQRS case finding
processes at the centers and, potentially, IT changes where case finding is
automated. Moreover, for some centers, the RQRS measures require concurrent
and duplicative abstraction because of the separate NCDB abstraction and
submission process. Therefore, there may be additional resource requirements
for some centers. Is there a better measure available or does a measure
already in the program set address a particular program objective? No.
(Submitted by: Alliance of Dedicated Cancer Centers)
| (Program: PPS-Exempt Cancer Hospital Quality Reporting
Program ; MUC ID: E0225) |
- Position: Do not adopt this measure. Relevance: Many patients with AJCC
stage I, II, or III colon cancer receive their surgical resections at the
Cancer Centers and are, therefore, appropriate candidates for this measure.
Appropriate attention should be given to facilities with patient populations
that deviate from the tested/studied cohorts; adjustments should be made to
the specifications accordingly. Usability: This measure evaluates an
important standard of care for patients with AJCC stage I, II, or III colon
cancer. However, high concordance rates (95-99%) among the Cancer Centers
limit the usefulness of this measure to drive improvement in our patient
populations. When these measures were originally collected by the Cancer
Centers, improved concordance rates were observed. Of note, the Cancer
Centers continue to closely follow our performance on these measures to ensure
continued adherence to the evidence-based guidelines. However, most have seen
maximum improvement and do not see anticipate further benefit from collection
as part of the PCHQR. These measures may be beneficial for community-based
oncology care where care delivery is not routinely integrated. However,
adoption of this measure for the PCHQR for purposes of establishing benchmarks
for the IQR program is not an efficient use of PCH or CMS resources. No other
measures in the PCHQR program address this aspect of patient care.
Feasibility: Since the measure is already reported via RQRS by the ADCC, no
additional burden is anticipated for centers with continued reporting.
(Submitted by: Alliance of Dedicated Cancer Centers)
- The MAP Hospital Workgroupís provisional recommendation is ìconditional
supportî for the inclusion of this measure in the PPS-Exempt Cancer Hospital
Quality Reporting program. However, the ACS strongly recommends full ìsupportî
of this NQF-endorsed measure. Since 2007, the National Cancer Data Base has
reported facility-level compliance with this measure to approximately 1500 CoC
accredited programs. CoC-accredited cancer programs have increased compliance
with this measure since it was released. If it would improve the expediency
of providing this valuable information to the public, we recommend progressing
inclusion of this measure in both the PPS-Exempt Cancer Hospital Quality
Reporting program and the IQR program. Though compliance with this measure is
generally high, this measure is clinically significant enough to remain as an
important benchmark for public reporting among all types of hospitals
providing cancer care as it is critical to impact the outcome of care. This
measure is also currently being reported publicly through the voluntary PHCQA,
http://www.phcqa.org/. (Submitted by: The American College of
Surgeons)
- [Pre-workgroup meeting comment]
aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa(Submitted
by: None)
- [Pre-workgroup meeting comment] Position: The ADCC does not support
measure inclusion in the PCHQR program because of very high concordance rates
among facilities and minimal opportunity for quality improvement. Would
addition of the measure add value to the program measure set? Most ADCC
facilities reported ìtopped outî performance from 95-99%. Therefore, this
measure offers little value for the PCHQR program. What is the measureís
potential to improve patient outcomes? This is an RQRS measure currently
reported by the ADCC. However, as noted above, our centers have high levels of
compliance, limiting the potential to improve patient outcomes. Would use of
the measure create undue data collection or reporting burden? Since this
measure is already reported through RQRS by the ADCC, no additional burden
would be experienced by centers. Is there a better measure available or does a
measure already in the program set address a particular program objective? No.
(Submitted by: Alliance of Dedicated Cancer Centers)
| (Program: Hospital Outpatient Quality Reporting
Program; MUC ID: E0291) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0292) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
- [Pre-workgroup meeting comment] Yes, under certain conditions -
Development of health information technology can improve the communication
between facilities. (Submitted by: Academy of Managed Care
Pharmacy)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0293) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
- [Pre-workgroup meeting comment] Development of health information
technology can improve the communication between facilities. Also require
needing a comprehensive list of medication history (for example opioid claims
that member may not use their insurance card for but is available in pdmp
data. Medical information should include medication action plans developed as
part of MTM pharmacist interventions. Note that HIEs often make it difficult
for pharmacist provider data to be sent via HIT to EMR. (Submitted by: Academy
of Managed Care Pharmacy)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0294) |
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0295) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0296) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0297) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- ACEP supports the timely transmission of medical records to the receiving
facility for transferred patients, which is already required by law in most
states. However, regarding the measures E0291-E0297 (including Administrative
Communication, Vital Signs, Medication Information, Patient Information,
Physician Information, Nursing Information, and Procedures and Tests), ACEP
has some concerns regarding the feasibility of data abstractors to adequately
define and capture the specific components. The information related to the
specific component may be included in the medical record communicated, but it
may be challenging for abstractors to distinguish the components. For
instance, vital signs and medication information may be documented by nurses
as part of the nursing notes, and thus be included in ìnursing informationî.
ACEP has recently worked with CMS in 2012 to try to implement a similar
measure (formerly known as OP-19) in which ìmajor tests and proceduresî were
difficult to define, because the information on ìtests and proceduresî might
not be clearly labeled as such, but rather captured in a doctorís note. In
addition, test results may not be available from the lab at the time patients
are transferred. For these two reasons,ACEP strongly supports merging these
components into a single, comprehensive measure that the ìcomplete medical
recordî which was available at the time of transfer, was communicated to the
receiving facility, rather than creating an unwieldy multi-component
composite. ACEP would also strongly encourage the measure developers to
resubmit the comprehensive measure for NQF MAP consideration during the
2015-2016 pre-rulemaking process, if their intention is to revise the measure
into a comprehensive measure as stated in the MAP report. ACEP also strongly
supports efforts to standardize how the various components of the medical
record are presented in various EHR systems and health information exchanges
(HIEs) in order to facilitate and health IT infrastructure that supports care
coordination efforts such as this in the future.(Submitted by: American
College of Emergency Physicians Quality & Performance
Committee)
- Recommend resolution of previously identified issues with OP-19. Would
urge the ability to report this electronically. (Submitted by: Park Nicollet
Methodist Hospital)
| (Program: Ambulatory Surgical Centers Quality Reporting Program ;
MUC ID: E0326) |
- [Pre-workgroup meeting comment] The ASC Quality Collaboration has a
number of concerns regarding this measure. Foremost among these is that it
cannot be applied to the ASC setting as currently specified and endorsed. We
have reviewed the 2012 Measure Submission Form completed by the NCQA (the
developer and contact for this measure) and submitted to the NQF during the
measureís last endorsement cycle. While the denominator statement is ìAll
patients aged 65 years and olderî, the denominator details provided by the
NCQA make it clear that the denominator is calculated by determining an
eligible subset of all patients aged 65 and older. This subset is defined as
those eligible patients who received selected services (as defined by a list
of CPT codes) during the denominator time window. Therefore, to be included
in the denominator, the patient must be of an appropriate age on the date of
the encounter AND have one of the listed CPT codes submitted for the
encounter. The staff of the NCQA has confirmed that this is correct. All of
the CPT codes listed in the measure specifications for the denominator
calculation represent evaluation and management (E&M) services. Per
Federal regulation, ASCs operate exclusively for the purpose of providing
surgical services. This exclusivity means that an ASC may not provide
evaluation and management services. Hence, none of the E&M CPT codes
listed in the measure specifications are applicable to the ASC setting. As a
result, the measure denominator would always be zero in an ASC. If supporting
documentation is needed, please reference 42 CFR ß416.2, the CMS State
Operations Manual Appendix L, and Addenda AA and BB of the annual CMS ASC
payment files for ASC approved HCPCS codes. It does not make sense to apply
this measure to the ASC setting.(Submitted by: ASC Quality Collaboration (ASC
QC))
- [Pre-workgroup meeting comment] ASCA is supportive of the ASC
Quality Reporting Program, and encourages the development of more measures
that speak to the quality of care being provided in the ASC setting.
Unfortunately we do not believe this measure achieves this goal, based on the
following issues: -The measure denominator is specified by a group of
evaluation and management CPT codes, none of which are payable in the ASC. As
a result, the measure denominator would be zero for an ASC. -This measure has
not been tested or endorsed for the ASC setting. If it had been evaluated at
even the most superficial level prior to being included on the MUC List,
someone would have noticed the issue above. -The CMS Conditions for Coverage
(CfCs) for ASCs already require documentation of whether or not the patient
has an advance directive (see 416.50(c)(3)), so we think this can be
considered ìstandard of careî in the industry and doubt this is a meaningful
target for quality improvement. We do not support measures that ìauditî
compliance with the CfCs. Thank you for your consideration of our comments.
(Submitted by: Ambulatory Surgery Center Association)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
E0326) |
- AGS agrees that this is an important measure and believes that every
patient should have an advanced directive. (Submitted by: American Geriatrics
Society)
- This is too difficult to measure. The most important intervention would be
to assure that the patient has a primary care provider. Then measure this in
primary care.(Submitted by: Johns Hopkins Hospital)
- Although Premier agrees that all patients should have an advance care plan
in place, we are concerned about how this is being collected and measured.
This is essentially a binary measure of whether the advanced care plan was
discussed. We are concerned that 1) it will lead to repetitively raising the
same question at all clinical encounters, 2) at not all encounters is this an
appropriate topic (e.g. consultation for a skin rash) 3) it can devolve into a
ìcheck the boxî measure. The discussion of advanced directives and surrogates
requires a cultural shift in health care and that shift is not likely to be
accomplished by the payment and reporting system. Though an important goal,
discussion of advance directives is not likely to be advanced by this measure.
(Submitted by: Premier, Inc.)
- The ACS does not support the inclusion of this measure into the Hospital
Outpatient Quality Reporting Program (OQR). Measure E0326 was discussed
extensively by the MAP, but the workgroup was not able to reach consensus.
Therefore, the measure will go to the MAP Coordinating Committee for the final
vote. The ACS agrees that this is a critical measure for the inpatient
population. However, the discussion of an advanced care plan is not always an
appropriate conversation for every outpatient clinical scenario given the
broad range of minor procedures. (Submitted by: The American College of
Surgeons)
- Agree with concerns as stated in the MAP rationale.(Submitted by: Park
Nicollet Methodist Hospital)
- [Pre-workgroup meeting comment] A GENERAL COMMENT ON THE COMPLETE
LACK OF ANY PROPOSED METRICS FOR CAREGIVERS - -CMS still proposes no measures
of caregiver experience or burden. This is now standard for all persons with
self-care disability seen in the Veterans Health System. Caregivers are
mentioned in scores of places in the CMS list of measures, but only as being
decision-makers or suffering with patients. We need to measure whether the
care system has identified the caregiver(s), whether they have the skills and
commitment to provide the care, whether they are overwhelmed, and what
services they need. We would never take care of children without identifying
their parents or guardians, and without considering whether those caregivers
are capable of the demands being put upon them, and whether they need training
or other services. Yet we expect untrained and often dragooned family members
and even neighbors to take care of difficult incompetent older people without
even being mentioned in the record or having their capacity for caregiving or
their own well-being considered.(Submitted by: Altarum Institute Center for
Elder Care and Advanced Illness)
| (Program:
Hospital Value-Based Purchasing Program; MUC ID: E0351) |
- AdvaMed supports the MAP recommendation for conditional support pending a
review by the relevant NQF Standing Committee of the reliability and validity
testing of this measure for the Medicare fee-for-service population.(Submitted
by: AdvaMed)
- The ACS supports the MAP Hospital Workgroupís recommendation of
ìconditional supportî of this measure for Hospital Value-Based Purchasing
Program (HVBP), pending 1) review by the relevant NQF Standing Committee, and
2) adding Do Not Resuscitate (DNR) to the measure exclusions. The MAP
conditionally supported this measure pending a review by the relevant NQF
Standing Committee of the reliability and validity testing results. Because
this measure is being proposed for the HVBP program, a pay-for-performance
program, it is critical that this measure does not result in the
misclassification of care. Therefore, we agree that this measure should meet
the highest level of the reliability and validity standards as determined by
the relevant NQF Standing Committee. Furthermore, it is critical that DNR is
added to the measure exclusions so that providers are not penalized for the
DNR wishes of the patient. (Submitted by: The American College of
Surgeons)
- Premier agrees that understanding and eliminating preventable mortality is
a top priority. We support the concept of this measurement. However we are
concerned that the validity of the measure, which is entirely ICD-9 based, is
not yet fully know. The measure may be an excellent screening tool for
institutions, however unless we can know the false positive and false negative
rate, which at this point are unknown, we are unable to support this measure
for public reporting. Premier uses this measure in its own improvement
collaboratives as a reporting tool, however we have discovered numerous
incidences in which the measure was identifying a preventable condition , when
in fact this was not the case. We feel further testing and validation are in
order before this measure is considered for public reporting. (Submitted by:
Premier, Inc.)
- [Pre-workgroup meeting comment] This measure is of the utmost
importance, as currently available patient monitoring technologies may permit
ìearly warningî of complications and permit intervention before complications
worsen.(Submitted by: AdvaMed)
| (Program: Inpatient Rehabilitation Facilities Quality
Reporting Program; MUC ID: E0371) |
- As expressed in comments sent during the early comment period made
available by NQF in December 2014, we remain very concerned about the four
functional measures under consideration for federal programs. We appreciated
that the draft report reflects our recommendation as it pertains to this
measure. As we noted in our comments, AMRPA is supportive of this measure.
Many of our members are already collecting data on it and, while burdensome,
the potential for improving the quality of care for patients is significant.
However, we do not understand why patients with stays in excess of 120 days
are excluded. From a data collection standpoint it would be very burdensome to
remove patients with stay in excess of 120 from the analysis. Unless an
appropriate rationale can be provided, we would encourage the measure steward
to reconsider this exclusion. In addition, we disagree stroke patients should
be excluded from this measure. While not all stroke patients are appropriate
candidates for VTE prophylaxis, many are. Perhaps a more appropriate approach
would be to include stroke patients unless contraindicated.(Submitted by:
American Medical Rehabilitation Providers Association)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- The Joint Commission appreciates the support for this measure. As a point
of clarification, it is important to note that stroke patients are excluded
from this measure in order to avoid redundancy, in that there is a distinct,
NQF-endorsed measure specific to stroke patients (NQF #0434). Patients with
lengths of stay longer than 120 days are excluded because this measure is used
by CMS in its Hospital IQR program, and the 120 day exclusion corresponds with
the inpatient Medicare billing cycle.(Submitted by: The Joint
Commission)
- [Pre-workgroup meeting comment] AMRPA is supportive of this
measure. Many of our members are already collecting data on it and, while
burdensome, the potential for improving the quality of care for patients is
significant. However, we do not understand why patients with stays in excess
of 120 days are excluded. From a data collection standpoint it would be very
burdensome to remove patients with stay in excess of 120 from the analysis.
Unless an appropriate rationale can be provided, we would encourage the
measure steward to reconsider this exclusion. In addition, we disagree stroke
patients should be excluded from this measure. While not all stroke patients
are appropriate candidates for VTE prophylaxis, many are. (Submitted by:
American Medical Rehabilitation Providers Association)
- [Pre-workgroup meeting comment] Venous thromboembolism (VTE)
prophylaxis is a standard of practice and common place in the majority of
rehabilitation hospitals. FAH supports a VTE Prophylaxis measure and believes
that appropriate VTE prophylaxis can significantly affect a patientís medical
status. However, this measure is not appropriately specified for an
inpatient rehabilitation facility setting. While the stroke appropriate
disgnosis code is appropriate for the inpatient setting, this exclusion is not
appropriate in teh IRF setting where the patient will be admitted with full
knowledge of the severity of the stroke. Stroke is one of the most common
conditions treated at an inpatient rehabilitation hospital. Almost 17% of the
133,000 patients admitted to HealthSouth hospitals (trailing 4 quarters of
data as of November 1, 2014) had a primary diagnosis of stroke. Excluding
this population of patients from being screened for VTE prophylaxis is not
appropriate. Additionally, we do not understand the exclusion of patients
with stays over 120 days. Given this is a documentation requirement that
occurs the day of admission, it is impossible for hospitals to know if a
patient will stay greater than 120 days. The FAH recommends that this measure
or a measure of similar focus be included in the skilled nursing facility
setting as well. This will facilitate understanding of VTE across all
settings of care. (Submitted by: Federation of American
Hospitals)
- [Pre-workgroup meeting comment] Venous thromboembolism (VTE)
prophylaxis is a standard of practice and common place in HealthSouth
rehabilitation hospitals. We support this as a measure and believe that
appropriate VTE prophylaxis can significantly affect a patientís medical
status. However, while the exclusion of patients with an appropriate
diagnosis code may be appropriate in inpatient acute care settings because the
type of stroke as not yet been identified, this exclusion does not make sense
for inpatient rehabilitation hospitals. Stroke is one of the most common
conditions treated at an inpatient rehabilitation hospital. Almost 17% of the
133,000 patients admitted to HealthSouth hospitals (trailing 4 quarters of
data as of November 1, 2014) had a primary diagnosis of stroke. Excluding
this population of patients from being screened for VTE prophylaxis is not
appropriate. Additionally, we do not understand the exclusion of patients
with stays over 120 days. Given this is a documentation requirement that
occurs the day of admission, it is impossible for hospitals to know if a
patient will stay greater than 120 days. Additionally, given this measure is
being proposed or already in place for Hospital Inpatient Quality Reporting,
Inpatient Rehabilitation Facility Quality Reporting, and Long-Term Care
Hospital Quality Reporting, we would support this measure this or a similar
measure to also be proposed for Skilled Nursing Facilities. (Submitted by:
HealthSouth Corporation)
- [Pre-workgroup meeting comment] We agree with this measure as
screening and documentation are alredy a standard process for IRFs(Submitted
by: HealthSouth)
- [Pre-workgroup meeting comment] This is a standard practice in
IRFs. I disagree with exluding stroke patients, but overall this measure is a
relavant medical issue.(Submitted by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] This is a good measure and very
applicable to inpatient rehabilitation. Many of our patients come to us on
prophylaxis already, but some do not. It makes sense to have inpatient
rehabilitation hospitals and units be that second check in preventing venous
thromboembolism. The piece that does not make sense in excluding stroke
patients. As the post acute provider, the cause of the stroke is known, so
making certain that appropropriate anticoagulation is in place serves as a
double check os this important process. (Submitted by: HealthSouth
Corporation)
| (Program: Long-Term Care Hospitals Quality Reporting
Program; MUC ID: E0371) |
- We agree with the MAP rationale for conditional support of the VTE
prophylaxis measure, as the duration of VTE prophylaxis is dependent upon the
functional recovery in this setting. We support the exclusion for patients
with extended stays > 120 days as these patients are likely at a functional
status for which long-term VTE prophylaxis is greater risk than benefit. We
agree that exclusion for stroke patients is a concern.† Even patients with
hemorrhagic stroke receive VTE prophylaxis, defined in the clinical guidelines
of the American College of Chest Physicians as inflatable compression devices
initially, broadened often to include thrombolytic medications after
stabilization from the acute hemorrhage.(Submitted by: Armstrong Institute for
Patient Safety and Quality)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- The Joint Commission appreciates the support for this measure. As a point
of clarification, it is important to note that stroke patients are excluded
from this measure in order to avoid redundancy, in that there is a distinct,
NQF-endorsed measure specific to stroke patients (NQF #0434). Patients with
lengths of stay longer than 120 days are excluded because this measure is used
by CMS in its Hospital IQR program, and the 120 day exclusion corresponds with
the inpatient Medicare billing cycle.(Submitted by: The Joint
Commission)
| (Program: End-Stage Renal
Disease Quality Incentive Program ; MUC ID: E0419) |
- While medication reconciliation is an important safety measure, the check
box metric will not necessarily improve care. Focus should be to facilitate
the providers by providing real-time electronic prescription fill data rather
than check box penalization. (Submitted by: Johns Hopkins
Hospital)
- KCP recognizes that true medication reconciliation is an important and
high priority, but neither E0419 nor X3721 adequately address this aspect of
care. Both measures emerged from the PAC/LTC Workgroup with the designation
ìconsensus not reached;î the Workgroup voted 56% to 44% against conditional
support pending testing (E0419) and endorsement (X3721). KCP opposes both
E0419 and X3721 and urges the MAP Coordinating Committee to do likewise. We
believe the specifications are fundamentally flawed for the dialysis facility
setting and hence should be opposed. We note that while E0419 has been
endorsed for physician- and population-level use, there is a complete lack of
testing in dialysis facilities. Unlike the adequacy measures, where there is
both testing and experiential data on the components, CMS has not demonstrated
that E0419 is reliable and valid for dialysis facilities. Accordingly, E0419
should not rise to the level of ìconditional support,î as has been recommended
for the adequacy measures. Additionally, KCP believes E0419 and X3721 are
essentially ìcheckbox measuresî that are unlikely to improve medication
reconciliation. We also note that E0419 looks at the percentage of visits in
which a review of the medications occurs; we believe this is an inappropriate
specification when dialysis facilities are the care setting with, typically,
three or more treatments per week. Testing a measure would shed light on the
feasibility and validity/reliability of the current E0419 specifications as
presented, but has not been performed in dialysis facilities. Reliability and
validity demonstrated in other care settings should not be assumed to
transfer. We cannot overemphasize the importance of testing medications
documentation and reconciliation measures specifically at the dialysis
facility level. Again, we are acutely sensitive to the potential utility of a
valid medication reconciliation measure for patients with ESRD on dialysis,
because they take an average of 8 to 10 medications, prescribed by 4 to 6
different doctors. Further, all non-prescription medications and medications
prescribed by other providers must be included in the review. We believe
that, as currently specified, E0419 is not feasible and would yield inaccurate
data (as would X3721) because it is based on faulty specifications.
Accordingly, MAP should not conditionally support either measure.(Submitted
by: Kidney Care Partners (KCP) )
- 3. NKF recognizes that medication reconciliation addresses an important
gap in the care of dialysis patients. Drug interactions, dose adjustment for
dialysis and avoidance of certain medications are important elements of care.
However, we oppose the following measures for use in the ESRD QIP as they are
currently designed: ï X3721 Medications Documentation Reporting
ï E0419 Documentation of Current Medications in the Medical Record
Unfortunately, these measures do not address true medication reconciliation
and therefore will have limited effect on improving patient outcomes. The
measure does not specify who in the dialysis facility should obtain the
information or how it should be obtained. There is no requirement to
coordinate with outside providers or pharmacists and currently no systems in
place to ensure interoperability of electronic health records that could aid
in avoiding medication errors including harmful drug interactions. In
addition, this is a percentage of visits where a medication review occurs.
Given that in-center hemodialysis patients typically receive dialysis three
times per week and home dialysis patients may visit the dialysis facility once
a month or less we do not see how this measure can feasibly be implemented for
a dialysis facility as currently designed. NKF looks forward to working with
CMS and NQF on ways medication reconciliation can be improved for dialysis
patients. (Submitted by: National Kidney Foundation)
- [Pre-workgroup meeting comment] ASN support this measure in
concept. However, the society believes that defining when documentation or
reconciliation should occur and then testing this timing strategy is essential
for application to dialysis facilities. ASN agrees that identifying
medications and medication changes at admission to the dialysis unit, and with
each care setting transition is critical. However, ASN also notes that
reconciliation is not necessary at each routine dialysis session, preferring
serial regular reconciliation at an appropriate interval that should be
specified and tested given the balance between resource allocation and
benefits present in dialysis facilities.(Submitted by: American Society of
Nephrology)
| (Program: Medicare Shared
Savings Program; MUC ID: E0419) |
- ASN recognizes the critical importance of accurate medication
reconciliation and supports this measure in concept, but agrees with the
PAC/LTC Workgroup, who voted 56% to 44% against conditional support, that
additional measure testing and development is needed prior to this measure
being advanced. The society believes that defining when documentation or
reconciliation should occur and then testing this timing strategy is essential
for application to dialysis facilities. ASN agrees that identifying
medications and medication changes at admission to the dialysis unit, and with
each care setting transition is critical. However, ASN also notes that
reconciliation is not necessary at each routine dialysis session, preferring
serial regular reconciliation at an appropriate interval that should be
specified and tested given the balance between resource allocation and
benefits present in dialysis facilities. ASN would be pleased to work with
measure stewards to develop and refine this measure, which addresses a
critical patient safety issue.(Submitted by: American Society of Nephrology
(ASN))
- We are not supportive of measure as our review of the supporting
documentation does not show sufficient testing in ESRD facilities. More
testing needs to be done to determine feasibility in an ESRD
setting.(Submitted by: Davita Healthcare Partners)
| (Program: PPS-Exempt Cancer
Hospital Quality Reporting Program ; MUC ID: E0431) |
- Position: Adopt with modifications, as described below. Relevance:
Influenza vaccination among healthcare personnel is an important component of
federal and state public health policy. Studies have shown that inpatients of
locations where staff are vaccinated have less influenza-like illness (ILI)
and less morbidity due to ILI, demonstrating the significant influence of this
measure with regard to patient outcomes. As the ADCC solely cares for cancer
patientsóa particularly vulnerable populationóenforcement of this policy is
important in our hospitals. In some cases, healthcare workers that have
direct patient contact decline influenza vaccination and/or are medically
excluded. This measure would benefit from refinement to address appropriate
infection control practices for these employees. Usability: The ADCC
recognizes the importance of influenza vaccination coverage among healthcare
personnel as an important patient safety standard. Many of our facilities
already track compliance internally and report this metric according to
current state mandates. Therefore, its ability to improve patient safety may
be limited through its adoption for the PCHQR. No other measures in the PCHQR
program address this aspect of patient care. Feasibility: Many of our
facilities already report this metric according to current state mandates; no
additional burden is anticipated with continued reporting of the measure.
(Submitted by: Alliance of Dedicated Cancer Centers)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. (Submitted by: Service Employees International
Union)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] Position: We support the inclusion
of this measure in the PCHQR program and note that many of our facilities
already report this metric according to current state mandates.
Contraindications and exceptions for the measure should be clarified to ensure
reporting compliance. We recommend that the measure steward be contacted with
our concerns to make amenable edits. Would addition of the measure add value
to the program measure set? The ADCC believes this is a valuable measure to
include in the PCHQR program and will positively affect patient outcomes. What
is the measureís potential to improve patient outcomes? Studies have shown
that inpatients of locations where staff are vaccinated have less ILI and less
morbidity due to the ILI, demonstrating the significant influence of this
measure with regard to patient outcomes. Would use of the measure create
undue data collection or reporting burden? Many of our facilities already
report this metric according to current state mandates. No additional burden
is anticipated in reporting this measure. Is there a better measure available
or does a measure already in the program set address a particular program
objective? No. (Submitted by: Alliance of Dedicated Cancer
Centers)
| (Program: Medicare Shared Savings Program; MUC ID: E0465)
|
- The ACS supports the MAP Clinician Workgroupís recommendation for
continued development of this measure as a composite measure for the PQRS,
Physician Compare, and VBPM. This measure is reportable by vascular surgeons.
(Submitted by: The American College of Surgeons)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: E0465)
|
- Tiglacor is misspelled. The correct spelling is "ticagrelor."(Submitted
by: AstraZeneca Pharmaceuticals)
- The ACS supports the MAP Clinician Workgroupís recommendation for
continued development of this measure as a composite measure for the MSSP.
This measure is reportable by vascular surgeons. (Submitted by: The American
College of Surgeons)
| (Program: Hospital Value-Based Purchasing Program;
MUC ID: E0468) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program: Inpatient Quality Reporting Program ;
MUC ID: E0468) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- (Support with caveats) Premier agrees it is important to assess both
mortality and readmission rates for the pneumonia population. However, we
understand that the patient population covered by these measures has been
expanded to include aspiration pneumonia and pneumonia POA with sepsis and
other condition. We are concerned that this is a substantive change to the
definition that has many implications for providers and systems. Aspiration
pneumonia is a condition that occurs in debilitated patients such as stoke
victims, residents of nursing homes, patients in stupor, and patient in an
otherwise weakened state who are unable to protect their airways. Likewise
patients with pneumonia and sepsis are severely ill at the time of admission.
We are concerned that this measure has moved beyond its original scope of
community acquired pneumonia to include a substantially widened and
heterogeneous population and we have no data concerning the impact of this
change on hospital performance. We also lack data on the adequacy of the risk
adjustment methods for handling such a diverse population. More study is
needed before these measures can be publically reported and we hope the NQF
endorsement process for these measures will review this point. Premier is
also concerned that there is a potential for some metrics to be displayed on
hospital compare utilizing two different methodologies ñ old and new ñ and
this is potentially confusing. (Submitted by: Premier, Inc.)
- SHM agrees with the MAP recommendation for conditional support but
requests further clarification on exclusions for cancer patients, who may have
a disproportionately high mortality rate and affect the outcome of this
measure.(Submitted by: Society of Hospital Medicine)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program: Hospital Readmission Reduction Program
; MUC ID: E0506) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- Our opinion is to NOT support the addition of ICD-9 codes that include
aspiration pneumonia in this pneumonia readmission measure.† Community
acquired pneumonia (the original measure definition) and aspiration pneumonia
have entirely different mechanisms of origin. †The intent of these indicators
is to reduce preventable rehospitalization with known evidence and standard
interventions that can be applied in the hospital setting (such as
pneumococcal vaccination) .† Lumping these two categories of pneumonia into
one indicator muddies the outcome and comprehension of the factors
contributing to the readmission.† More importantly we DO NOT support the
renewal of the pneumonia readmission measure in any form, because there are
likely to be limited clinical interventions that can be implemented in the
hospital or post-discharge that are disease specific and are likely to prevent
rehospitalization.† After all pneumonia is not a chronic condition for which
preventative strategies are likely to prevent exacerbations or recurrences,
(besides pneumococcal vaccination which is measured through other quality
process metrics).† (Submitted by: Johns Hopkins Hospital)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program: Inpatient Quality Reporting Program ;
MUC ID: E0506) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- (Support with caveats) Premier agrees it is important to assess both
mortality and readmission rates for the pneumonia population. However, we
understand that the patient population covered by these measures has been
expanded to include aspiration pneumonia and pneumonia POA with sepsis and
other condition. We are concerned that this is a substantive change to the
definition that has many implications for providers and systems. Aspiration
pneumonia is a condition that occurs in debilitated patients such as stoke
victims, residents of nursing homes, patients in stupor, and patient in an
otherwise weakened state who are unable to protect their airways. Likewise
patients with pneumonia and sepsis are severely ill at the time of admission.
We are concerned that this measure has moved beyond its original scope of
community acquired pneumonia to include a substantially widened and
heterogeneous population and we have no data concerning the impact of this
change on hospital performance. We also lack data on the adequacy of the risk
adjustment methods for handling such a diverse population. More study is
needed before these measures can be publically reported and we hope the NQF
endorsement process for these measures will review this point. Premier is
also concerned that there is a potential for some metrics to be displayed on
hospital compare utilizing two different methodologies ñ old and new ñ and
this is potentially confusing. (Submitted by: Premier, Inc.)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. Research has proven that lower-income patients
have greater difficulty affording medications, copays, or transportation to
post-discharge appointments which are factors that increase the risk of
hospital readmission. In fact a recent study reported in Health Affairs
revealed that patients living in low-income neighborhoods were 24 percent more
likely to be readmitted to the hospital after adjusting for demographic
characteristics. Socioeconomic Status And Readmissions: Evidence from an
Urban Teaching Hospital ñ
(http://content.healthaffairs.org/content/33/5/778.abstract) As the
Association of American Medical Colleges notes, ìWhile lowering readmissions
is a worthy goal, the rush to impose financial penalties on provider
performance for ìaccountabilityî measures, such as readmission rates, has the
unintended consequence of disproportionately penalizing doctors and hospitals
providing safety-net care.î (Submitted by: Service Employees International
Union)
- We agree with the MAP's preliminary recommendation for conditional
support, but add that the measure developer should consider adjusting for or
excluding co-morbid CHF diagnoses.(Submitted by: Society of Hospital
Medicine)
- [Pre-workgroup meeting comment] A GENERAL COMMENT ON THE
DEFICIENCIES OF ALL OF THE PROPOSED MEASURES THAT USE THE GENERAL FORM
READMISSIONS/DISCHARGES: CMS has many readmissions measures (e.g., X3701,
X3727, and s2510) for upcoming use. All that are in the review document are
of the form ìreadmissions/dischargesî and some are risk-adjusted for severity
of illness (but none for socio-economic issues). CMS should be doing at least
these three things at this point: (1) All readmissions/discharges metrics
should have numerator and denominator reported, as well as the rate; and, in
use, they should be interpreted with attention to the possibility that a very
low or shrinking denominator might make it difficult to detect that the
pattern of practice is actually quite good; (2) All readmissions metrics
should carry a caveat about the potential for social supports and community
resources to affect the determination, and (3) The readmissions/1000 and
admissions/1000 metrics that have been presented to NQF should be in the list
of potentially useful metrics for CMS, since population-based measures might
well come to modify the application of other metrics in situations where
attribution of populations is possible, as it is for community-based
improvement activities (QIO work) and for settings where single hospitals or
multiple cooperating hospitals can be judged together.(Submitted by: Altarum
Institute Center for Elder Care and Advanced Illness)
| (Program: Medicare Shared Savings Program; MUC ID:
E0514) |
- This measure, under consideration for the MSSP, calculates the percentage
of MRI Lumbar Spine studies with a diagnosis of low back pain on the imaging
claim and for which the patient did not have prior claims-based evidence of
antecedent conservative therapy. The MAP recommends ìconditional support
pending resolution of data concerns.î Specifically, the MSSP may have
difficulty accessing National Healthcare Safety Network (NHSN) data and would
need to coordinate with the CDC to obtain the information. MAP also
acknowledges concerns raised by providers specializing in the treatment of
spinal cord injuries and encourages further consideration on the trade-offs of
including these patients in this measure population. In addition to these
concerns, the AANS and CNS believe this measure must allow for the
identification and exclusion of those patients with specific concerning signs
or symptoms (i.e., ìred flagsî) from the measure before it can be used for
accountability purposes.(Submitted by: American Association of Neurological
Surgeons/Congress of Neurological Surgeons)
- NASS disagrees with MAPís support of this measure. This measure calculates
ìthe percentage of MRI of the lumbar spine studies with a diagnosis of low
back pain on the imaging claim and for which the patient did not have prior
claims-based evidence of antecedent conservative therapy.î Those with
low-performance rates are considered to be in compliance with this measure.
While we agree in theory with the concept of overuse measures, we believe that
the focus of this measure is too narrow. This measure may unfairly categorize
some providers as over-users of MR imaging when they are in fact providing
standard of care. For example, this measure fails to recognize those patients
seen for the first time with a history of chronic low-back pain greater than
60 days. The consequences of this include (1) unfairly labeling those
providers who order MR imaging for their chronic pain patient as over-users;
(2) over-utilization of PT or chiropractic services or (3) significant delay
in the diagnosis and appropriate treatment regimen. Due to these reasons, NASS
recommends that patient history of chronic low-back pain (> 60 days) be
listed among the exclusion criteria. In addition, as written in the
exclusions, it is unclear if those with clinical suspicion of spinal tumor,
fracture, neurologic impairment or infection are also covered under exclusions
or just those with the actual diagnosis code of one of these conditions.
(Submitted by: North American Spine Society)
- NASS disagrees with MAPís support of this measure. This measure calculates
ìthe percentage of MRI of the lumbar spine studies with a diagnosis of low
back pain on the imaging claim and for which the patient did not have prior
claims-based evidence of antecedent conservative therapy.î Those with
low-performance rates are considered to be in compliance with this measure.
While we agree in theory with the concept of overuse measures, we believe that
the focus of this measure is too narrow. This measure may unfairly categorize
some providers as over-users of MR imaging when they are in fact providing
standard of care. For example, this measure fails to recognize those patients
seen for the first time with a history of chronic low-back pain greater than
60 days. The consequences of this include (1) unfairly labeling those
providers who order MR imaging for their chronic pain patient as over-users;
(2) over-utilization of PT or chiropractic services or (3) significant delay
in the diagnosis and appropriate treatment regimen. Due to these reasons, NASS
recommends that patient history of chronic low-back pain (> 60 days) be
listed among the exclusion criteria. In addition, as written in the
exclusions, it is unclear if those with clinical suspicion of spinal tumor,
fracture, neurologic impairment or infection are also covered under exclusions
or just those with the actual diagnosis code of one of these
conditions.(Submitted by: North American Spine Society)
- Comment on Outpatient MRI for Low Back Pain without Treatment E0514 C.
Craig Blackmore, MD MPH Director, Center for Health Services Research Virginia
Mason Medical Center, Seattle, WA Chair, Washington State Health Technology
Clinical Committee Member, Washington State Performance Measures Coordinating
Committee This measure, E0514, is designed to measure the appropriate
utilization of lumbar MRI in patients with low back pain, and is taken from
CMS OP-8. Lumbar MRI is overused, particularly in patients with
disc/degenerative disease that might be self limited, or respond to
conservative care. The intent of the metric is great, but there is strong
potential for unintended consequences. A major concern with this measure it
that it does not directly measure lumbar MRI utilization, but rather measures
use of physical therapy among individuals who undergo MRI. The idea is that
by encouraging physical therapy, the use of MRI might decrease. However, this
is not actually measured. In practice, the metric may be improved by either
increasing use of physical therapy prior to MRI (numerator), OR by increasing
the number of MRI scans (denominator), by doing more unnecessary scans post
physical therapy. First the numerator: Increasing physical therapy may
decrease inappropriate MRI. However, these individuals will no longer be
represented in the measure (in the numerator or denominator) as they are no
longer getting MRI, so it is not clear that eliminating these unnecessary
scans will actually change the score on the metric. Second the denominator:
Most individuals will develop low back pain in the course their lifetime. For
the vast majority, conservative care, potentially including physical therapy
will lead to resolution in a relatively short time frame. Most of these
individuals do not need MRI scans, but may inappropriately get scanned.
Unfortunately, under this metric, scanning more of these people will
potentially cause a better score if the scan is performed after 28 days of
physical therapy. Conversely, a group that practices appropriately and does
not perform MRI on patients with self-limited conditions could get a worse
score, as the patients who do not undergo MRI will be absent from both the
numerator and denominator. Examples: Based on 100 patients with low back
pain. Assume 1) 10 have an indication for immediate MRI based on age, or some
other risk factor for more serious disease (though these will be considered
inappropriate under the measure), 2) 20 will have no response in symptoms
despite appropriate conservative therapy, and therefore could be considered
appropriate use of MRI after initial conservative therapy. Numerator is
patients NOT meeting E0514 criteria for appropriate Denominator is number of
MRIs performed. Higher scores are bad. Example 1: Extreme inappropriate of
MRI. All patients get immediate MRI. Numerator (not meeting criteria for
appropriate): 100 Denominator: 100 E0514 score: 1.0 MRIs avoided: 0 Example 2:
Severe, but delayed inappropriate of MRI 10 patients get immediate MRI because
of advanced age, prior surgery, etc. All other patients get initial physical
therapy: 40 fully respond, 30 partial respond, 20 no response. Partial and no
response patients get MRI after initial therapy Numerator (not meeting
criteria for appropriate): 10 (the few immediate MRI scans, all other patients
got PT) Denominator: 60 (partial and non-responders) E0514 score: 0.17 MRIs
avoided: 40 Example 3: Appropriate control of MRI use* 10 patients get
immediate MRI because of advanced age, prior surgery, etc. All other patients
get initial physical therapy: 40 fully respond, 30 partial respond, 20 no
response. Only patients without any improvement on PT get MRI Numerator (not
meeting criteria for appropriate): 10 (the few immediate MRI scans, all other
patients got PT) Denominator: 30 E0514 score: 0.33 MRIs avoided: 70 *Note that
the most desirable scenario, with aggressive control of MRI utilization
actually causes a worse score than scenario 2, which includes substantial
overutilization. Unfortunately, this is the scenario we encounter at Virginia
Mason, where our aggressive clinical decision support system has led to marked
decrease in inappropriate lumbar MRI (published in Blackmore CC, Mecklenburg
RS, Kaplan GS. ìEffectiveness of clinical decision support in controlling
inappropriate imaging.î J Am Coll Radiol 2011;8:19-25), with a decrease in the
denominator of the E0514 metric, an effect not captured by the E0514 metric.
It is also worth noting that this metric differs from the Washington State
Health Alliance metric that actually looks at patients diagnosed with low back
pain as the denominator, rather than patients who got MRI. (Submitted by:
Virginia Mason Medical Center)
| (Program:
Ambulatory Surgical Centers Quality Reporting Program ; MUC ID: E0515)
|
- [Pre-workgroup meeting comment] This measure focuses on a process
of care that is associated with reduced rates of surgical site infection, and
has been endorsed by NQF since 2007. Over the last seven years it has been
used by thousands of ASCs participating in the ASC Quality Collaborationís
public reporting program, which posts aggregated quarterly results online.
Our experience suggests the measure data is usable, and that data collection
and reporting is not unduly burdensome. (Submitted by: ASC Quality
Collaboration (ASC QC))
| (Program: Medicare Shared Savings Program; MUC ID: E0555)
|
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy )
| (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID: E0555)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: E0555) |
- AGS agrees that this should be included as a safety measure. (Submitted
by: American Geriatrics Society)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Inpatient
Quality Reporting Program ; MUC ID: E0642) |
- AdvaMed supports the MAP recommendation for conditional support of this
measure pending resolution of specific data concerns. Cardiac rehabilitation
has been shown to significantly reduce mortality rates and continued
cardiovascular events such as readmissions. Referrals to cardiac
rehabilitation for patients admitted who undergo CABG, PCI, CVS, or cardiac
transplantation can result in increased enrollment in cardiac rehabilitation
and potentially improved outcomes for patients undergoing these procedures.
This measure addresses a known gap in care transitions and referrals to the
next site of care, as cardiac rehabilitation remains underused.(Submitted by:
AdvaMed)
- January 12, 2015 Re: E0642 Cardiac Rehabilitation Patient Referral from
an Inpatient Setting To Whom It May Concern: We strongly support the
endorsement and full implementation of performance measure E0642, Cardiac
Rehabilitation Patient Referral from an Inpatient Setting, for the reasons
listed below: 1. Key Window of Opportunity: Since the majority of patients
who need cardiac rehabilitation have been hospitalized for a cardiac event,
the inpatient period is a critically important time for referral of
appropriate patients to cardiac rehabilitation. 2. Class 1 Indication:
Referral to a cardiac rehabilitation (CR) outpatient program upon discharge is
a Class I indication in clinical guidelines for MI, PCI, CABG, chronic stable
angina, and most recently, heart failure. 3. Strong Evidence of Benefits:
Evidence demonstrates that participation in early outpatient CR results in:
ï Reduced all-cause mortality ranging from 15%-28%1 ï Reduced cardiac
mortality from 26%-31% ï Reduced cardiovascular events ï Reduced readmission
rates to hospital2 ï A strong dose-response relationship between # of CR
sessions and long-term outcomes2 ï Improved adherence with preventive
medications4 ï Improved function and exercise capacity ï Improved quality of
life ï Improved modifiable risk factors5 4. Low Utilization: Despite the
evidence of benefit, CR is underutilized, with only 14-35% of MI survivors and
31% of patients after CABG participating in CR.6 5. Systematic Approaches
Improve Utilization: Lack of physician referral has been identified as a
major barrier to participation. Increased use of CR has been demonstrated
through the use of quality indicators, such as automatic referrals for
qualifying hospital admissions, as in the NCDR Registry. One example of this
was AHAís Get with the Guidelines (GWTG) program which had a referral rate of
56%, well above national averages.7 6. Low Burden of Work to Collect: As has
been demonstrated in the NCDR Registry, which includes the cardiac
rehabilitation referral measure, the inclusion of referral to CR in automated
hospital discharge order sets does not create undue reporting burden.
7. Increased Accountability Helps Improve Service Delivery: The treatment
gap between scientific evidence of the benefits of CR and clinical
implementation of CR is most effectively addressed with this process
improvement measure to reduce the health system barrier of poor referral rates
to CR. There is no better measure or strategy currently available that
demonstrates a comparable outcome in improved referrals. This performance
measure increases accountability of health care providers and healthcare
systems. Quality-enhancing policies such as the inclusion of CR referral as a
core quality-of-care measure for hospitals and public reporting of each
hospitalís adherence to the AACVPR/ACCF/AHA cardiac rehabilitation performance
measures will have a positive impact on program referral, enrollment, and
completion.8 8. Unique measure: This measure is not duplicative of any other
measures under consideration by CMS for 2015. It was developed in combination
with the performance measure titled, ìCardiac rehabilitation referral from an
outpatient settingî (NQF # 0643/PQRS # 243). These measures were developed
concurrently to meet all possible points of entry for a patient who would
benefit from participation in cardiac rehabilitation. The focus of the
referral measure from an outpatient setting is to include those patients who
have had a qualifying event, but who have not yet been referred to an
outpatient cardiac rehabilitation program. It is not uncommon that a
hospitalized patient is not an appropriate candidate for referral to cardiac
rehabilitation at hospital discharge. The referral measure from an outpatient
setting is a process measure that is intended to facilitate enrollment into a
cardiac rehabilitation program when the patient is ready. Because patients who
qualify for CR do not necessarily come from a recent hospitalization, it is
necessary to have both measures to capture eligible patients who will benefit
from this treatment. Sincerely, Glenn A. Feltz President American
Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) References
1. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for
patients with coronary heart disease: systematic review and meta-analysis of
randomized controlled trials. Am J Med. 2004;116:682-692. 2. Dunlay SM, Pack
QR, Killian JM, Roger VL. Participation in cardiac rehabilitation,
readmissions, and death after acute myocardial infarction. Am J Med.
2014;127(6):538-546, doi: 10.1016/j.amjmed.2014.02.008. 3. Hammill BG, Curtis
LH, Schulman KA, Whellan JD. Relationship between cardiac rehabilitation and
long-term risks of death and myocardial infarction among elderly Medicare
beneficiaries. Circulation. 2010;121:63-70. 4. Shah ND, Dunlay SM, Ting HH, et
al. Long-term medication adherence after myocardial infarction: experience of
a community. Am J of Med. 2009;122(10)961.e7-13. 5. Suaya JA, Stason WB, Ades
PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older
coronary patients. J Am Coll Cardiol. 2009;54:25-33. 6. Suaya JA, Shepard DS,
Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by
Medicare beneficiaries after myocardial infarction or coronary bypass surgery.
Circulation. 2007;116:1653-1662. 7. Brown TM, Hernandez AF, Bittner V, et al;
on behalf of American Heart Association Get With the Guidelines Investigators.
Predictors of cardiac rehabilitation referral in coronary artery disease
patients: findings from the American Heart Associationís Get With the
Guidelines Program. J Am Coll Cardiol. 2009;54:515-521. 8. Thomas RJ, King M,
Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ACCF/AHA 2010 update:
performance measures on cardiac rehabilitation for referral to cardiac
rehabilitation/secondary prevention services: a report of the American
Association of Cardiovascular and Pulmonary Rehabilitation and the American
College of Cardiology Foundation/American Heart Association Task Force on
Performance Measures (Writing Committee to Develop Clinical Performance
Measures for Cardiac Rehabilitation). Circulation. 2010;122:1342-1350.
(Submitted by: American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) )
- AGS notes that the measure title does not specify which cardiac diagnoses
are included. However, for frail elders, it is unclear if disease specific
rehabilitation such as cardiac rehab is appropriate or if other rehabilitation
strategies geared toward frailty/functional and cognitive decline are more
appropriate. It does not appear that appropriate patient selection is
considered in this measure.(Submitted by: American Geriatrics
Society)
- Would urge the ability to report this electronically.(Submitted by: Park
Nicollet Methodist Hospital)
- January 12, 2015 Re: Support for performance measure E0642 (Cardiac
Rehabilitation Referral from an Inpatient Setting) to remain under
consideration by CMS for the Hospital Inpatient Quality Reporting System for
2015 To Whom it May Concern, I write this letter to offer my strongest support
possible for performance measure E0642 (Cardiac Rehabilitation Referral from
an Inpatient Setting) to remain under consideration by CMS for the Hospital
Inpatient Quality Reporting System for 2015. I am an actively practicing
general cardiologist at the University of Alabama at Birmingham who has
inpatient responsibilities caring for patients in the Coronary Care Unit and
providing inpatient cardiac consultation for patients admitted to other
services. In addition, I am actively involved in cardiovascular epidemiologic
and health services research examining the quality of care of patients with
cardiovascular diseases, including the appropriate use of cardiac
rehabilitation in those who qualify. The benefits of cardiac rehabilitation
are well studied and equally well documented, with clear benefits in extending
life and reducing the morbidity associated with living with cardiovascular
disease. In fact, referral to cardiac rehabilitation is considered a Class I
indication in numerous guidelines published by the American College of
Cardiology and the American Heart Association. However, despite this
substantial evidence base and multiple guideline recommendations, cardiac
rehabilitation remains underutilized. Unfortunately, a major barrier to the
efficient utilization of cardiac rehabilitation is the failure of the patient
to be referred. In 2009, a group led by me examined the rates and predictors
of cardiac rehabilitation referral among over 70,000 patients with coronary
artery disease who were discharged from US hospitals participating in the
American Heart Associationís ìGet With the Guidelinesî program (Brown TM, et
al. J Am Coll Cardiol 2009;54:515-521). We were dismayed to find that about
one half of eligible patients did not receive a referral to cardiac
rehabilitation prior to hospital discharge. This rate of referral is likely
an overestimate of nationwide rates, as one would expect that hospitals
agreeing to participate in a quality improvement program such as the ìGet With
the Guidelinesî program would have higher rates. Performance measures serve as
a mechanism to increase accountability for hospitals and physicians and
improve the quality of care delivered. Failure to include this performance
measure in the Hospital Inpatient Quality Reporting System would be
interpreted as a lack of endorsement of the importance of cardiac
rehabilitation services and risk decreasing referral and, thus, participation
in cardiac rehabilitation. Although a similar performance measure exists for
referral to cardiac rehabilitation from an outpatient setting, the inpatient
measure is important to prevent a gap in care following discharge from the
hospital and the establishment of outpatient care. In addition, frequently
patients feel that recommendations not provided while in the hospital and
subsequently implemented only after discharge are less important than those
they receive in the hospital. Not having a performance measure for referral
to cardiac rehabilitation from an inpatient setting would have the unintended
consequence of minimizing the importance of cardiac rehabilitation and likely
further increase the underutilization of this important service. In summary, I
strongly urge the committee to support performance measure E0642 (Cardiac
Rehabilitation Referral from an Inpatient Setting) to remain under
consideration by CMS for the Hospital Inpatient Quality Reporting System for
2015. This measure is vital for improving the quality of care of patients
with cardiovascular disease. _____________________________ Todd M. Brown, MD,
MSPH, FACC Assistant Professor of Medicine (Submitted by: practicing
physician)
- January 9, 2015 Re: E0642 Cardiac Rehabilitation Patient Referral from an
Inpatient Setting To Whom It May Concern: I am writing in the strongest
possible support for the endorsement and full implementation of performance
measure E0642, Cardiac Rehabilitation Patient Referral from an Inpatient
Setting. I am an experienced cardiologist who not only serves as Medical
Director of the large and multisite Cardiovascular and Pulmonary
Rehabilitation Program at University Hospitals of Cleveland, but also
practices clinical cardiology, caring for many patients hospitalized with
cardiovascular disease. Additionally, I am the Medical Director of Cardiac
Intensive Care for University Hospitals. I believe these roles provide me
with the perspective of not only the value of cardiac rehabilitation in
general, but the enormous benefit to individual and population health that
this Performance Measure would produce. There is robust evidence of the
clinical benefits of patient enrollment in cardiac rehabilitation, and indeed
it is a Class I indication in multiple relevant inpatient guidelines (e.g. MI,
PCI, CABG) composed and endorsed by numerous leading medical organizations.
Unfortunately, there is also ample evidence that this is an underused service,
with many patients simply not appropriately referred from the inpatient
hospital setting to this outpatient program. Fortunately, in the current
work environment, electronic medical records (such as the one at my
institution) make such referral, at least in theory, logistically
straightforward, easy, and with minimal physician and organizational burden.
ìReferral to Cardiac Rehabilitationî orders may be incorporated in admission
order sets, care paths, and discharge order sets and easily used by
responsible clinicians. The full implementation of this Performance Measure
would support this, as well as assure that physicians and institutions were
tracking such referral as an important quality metric, and taking proactive
steps to minimize gaps and disparities in the use of this important part of
the overall care of suitable patients. In the EMR environment tracking this
Performance Measure would not be unduly burdensome. This measure is unique,
and related to, but not duplicative of the performance measure titled,
ìCardiac rehabilitation referral from an outpatient settingî (NQF # 0643/PQRS
# 243). These two measures were developed concurrently to meet possible points
of entry for a patient who would benefit from participation in cardiac
rehabilitation. Indeed, typically more patients initially are informed
about and are referred to cardiac rehabilitation from the inpatient versus the
outpatient setting. Both measures are necessary, however, because some
patients who have had a qualifying clinical event are not appropriate
candidate for referral to cardiac rehabilitation at hospital discharge, some
may initially decline referral, and some may have been hospitalized at an
institution geographically quite distant from their home, making inpatient
referral not feasible. Furthermore, patients who qualify for cardiac
rehabilitation (e.g. with stable angina or systolic heart failure) may not
necessarily have experienced a recent hospitalization, making both inpatient
and outpatient measures necessary. Endorsement and full implementation of
Performance Measure E0642, Cardiac Rehabilitation Patient Referral from an
Inpatient Setting would enhance the care of many patients each and every day,
improve lives, and decrease mortality. I give it my full and unqualified
personal support. Richard A Josephson, MS, MD FACC, FAHA, FACP, FAACVPR
Harrington Heart & Vascular Institute University Hospitals Health System
Division of Cardiovascular Medicine Mailstop LKS 5038 11100 Euclid Avenue
Cleveland, Ohio 44106-5038 richard. josephson@uhhospitals.org Office:
(216) 844-2775 Cell: (330) 414-2905 (Submitted by: practicing
physician)
- January 12, 2015 Re: E0642 Cardiac Rehabilitation Patient Referral from
an Inpatient Setting To Whom It May Concern: I am writing to offer my support
for the endorsement and full implementation of performance measure E0642,
Cardiac Rehabilitation Patient Referral from an Inpatient Setting. As the
Medical Director of a large Cardiac and Pulmonary Rehabilitation Program at
Vanderbilt University Medical Center I have first-hand experience with the
value of cardiac rehabilitation in the secondary prevention of cardiovascular
disease. Multiple clinical guidelines including MI, PCI and CABG endorse a
referral to outpatient cardiac rehabilitation as a Class I indication, clearly
recognizing the significant evidence that exists in the literature.
Unfortunately, despite the evidence, cardiac rehabilitation continues to be
significantly underutilized. The evidence also clearly demonstrates that lack
of referral from the inpatient hospital setting to outpatient cardiac
rehabilitation is part of the problem. However, existing hospital
infrastructure (e.g., electronic medical records, order sets, discharge order
sets) could be leveraged to significantly improve the referral rate to this
vital outpatient service without significant burden to the referring clinician
or the hospital, but with full benefit to patients. Full implementation of
this Performance Measure would significantly improve the accountability for
hospitals and clinicians resulting in improved quality of care. The inpatient
setting is an important opportunity for clinical teams to impress the
importance of outpatient follow-up that improves patient outcomes. Failing to
include this performance measure in the Hospital Inpatient Quality Reporting
System signals a lack of support for patients along the continuum of care by
negatively impacting referrals to outpatient cardiac rehabilitation, and
ultimately affecting their participation in these vital programs that have
both short and long term health implications and benefits. I feel strongly
that full implementation of Performance Measure E0642, Cardiac Rehabilitation
Patient Referral from an Inpatient Setting would improve the quality of care
delivered to patients with cardiovascular disease. For the reasons Iíve
outlined above, I urge the committee to keep E0642 under consideration by CMS
for 2015. Thank you for your time and consideration. Sincerely, David G.
Liddle, MD Assistant Professor, Vanderbilt Internal Medicine and Sports
Medicine Medical Director, Vanderbilt Dayani Center for Health and Wellness
david.g.liddle@vanderbilt.edu (Submitted by: private physician)
- Edwards supports the MAP recommendation to include this outcome measure in
the Hospital Inpatient Quality Reporting program. Cardiac rehabilitation has
been shown to significantly reduce mortality rates and continued
cardiovascular events such as readmissions. Referrals to cardiac
rehabilitation for patients admitted who undergo CABG, PCI, CVS, or cardiac
transplantation can result in increased enrollment in cardiac rehabilitation
and potentially improved outcomes for patients undergoing these procedures.
This measure addresses a known gap in care transitions and referrals to the
next site of care, as cardiac rehabilitation remains underused.(Submitted by:
Edwards Lifeciences)
- As the MAP noted, cardiac rehabilitation continues to be underutilized,
despite strong evidence of its benefits, and we urge the MAP to support use of
the Cardiac Rehabilitation Referral from an Inpatient Setting measure without
condition for use in the Hospital Inpatient Quality Reporting Program.
Discharge from the hospital following a cardiac event presents an important
opportunity to refer patients who would benefit from it to cardiac
rehabilitation, facilitating increased enrollment and improving outcomes. The
proven benefits of cardiac rehabilitation and the potential for improving
outcomes that could be realized by adopting this measure are fully detailed in
the comments submitted by the American Association for Cardiovascular and
Pulmonary Rehabilitation and we fully support their comments. Perhaps most
importantly, we believe that the data concerns expressed by the MAP may be due
to a misunderstanding. Although our measure is collected by our registries,
there is nothing that prevents it from being reported by any hospital, free of
charge, regardless of whether they participate in a registry or not.
(Submitted by: American Heart Association/American Stroke
Association)
- While written comments were not provided, the commenter indicated they did
not support MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- [Pre-workgroup meeting comment] December 5, 2014 Re: E0642 Cardiac
Rehabilitation Patient Referral from an Inpatient Setting To Whom It May
Concern: We strongly support the endorsement and full implementation of
performance measure E0642, Cardiac Rehabilitation Patient Referral from an
Inpatient Setting, for the reasons listed below: 1. Key Window of Opportunity:
Since the majority of patients who need cardiac rehabilitation have been
hospitalized for a cardiac event, the inpatient period is a critically
important time for referral of appropriate patients to cardiac rehabilitation.
2. Class 1 Indication: Referral to a cardiac rehabilitation (CR) outpatient
program upon discharge is a Class I indication in clinical guidelines for MI,
PCI, CABG, chronic stable angina, and most recently, heart failure. 3. Strong
Evidence of Benefits: Evidence demonstrates that participation in early
outpatient CR results in: ï Reduced all-cause mortality ranging from 15%-28%1
ï Reduced cardiac mortality from 26%-31% ï Reduced cardiovascular events
ï Reduced readmission rates to hospital2 ï A strong dose-response
relationship between # of CR sessions and long-term outcomes2 ï Improved
adherence with preventive medications4 ï Improved function and exercise
capacity ï Improved quality of life ï Improved modifiable risk factors5 4. Low
Utilization: Despite the evidence of benefit, CR is underutilized, with only
14-35% of MI survivors and 31% of patients after CABG participating in CR.6
5. Systematic Approaches Improve Utilization: Lack of physician referral has
been identified as a major barrier to participation. Increased use of CR has
been demonstrated through the use of quality indicators, such as automatic
referrals for qualifying hospital admissions, as in the NCDR Registry. One
example of this was AHAís Get with the Guidelines (GWTG) program which had a
referral rate of 56%, well above national averages.7 6. Low Burden of Work to
Collect: As has been demonstrated in the NCDR Registry, which includes the
cardiac rehabilitation referral measure, the inclusion of referral to CR in
automated hospital discharge order sets does not create undue reporting
burden. 7. Increased Accountability Helps Improve Service Delivery: The
treatment gap between scientific evidence of the benefits of CR and clinical
implementation of CR is most effectively addressed with this process
improvement measure to reduce the health system barrier of poor referral rates
to CR. There is no better measure or strategy currently available that
demonstrates a comparable outcome in improved referrals. This performance
measure increases accountability of health care providers and healthcare
systems. Quality-enhancing policies such as the inclusion of CR referral as a
core quality-of-care measure for hospitals and public reporting of each
hospitalís adherence to the AACVPR/ACCF/AHA cardiac rehabilitation performance
measures will have a positive impact on program referral, enrollment, and
completion.8 Sincerely, Glenn A. Feltz President American Association of
Cardiovascular and Pulmonary Rehabilitation (AACVPR) References 1. Taylor RS,
Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with
coronary heart disease: systematic review and meta-analysis of randomized
controlled trials. Am J Med. 2004;116:682-692. 2. Dunlay SM, Pack QR, Killian
JM, Roger VL. Participation in cardiac rehabilitation, readmissions, and death
after acute myocardial infarction. Am J Med. 2014;127(6):538-546, doi:
10.1016/j.amjmed.2014.02.008. 3. Hammill BG, Curtis LH, Schulman KA, Whellan
JD. Relationship between cardiac rehabilitation and long-term risks of death
and myocardial infarction among elderly Medicare beneficiaries. Circulation.
2010;121:63-70. 4. Shah ND, Dunlay SM, Ting HH, et al. Long-term medication
adherence after myocardial infarction: experience of a community. Am J of Med.
2009;122(10)961.e7-13. 5. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard
DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll
Cardiol. 2009;54:25-33. 6. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas
J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after
myocardial infarction or coronary bypass surgery. Circulation.
2007;116:1653-1662. 7. Brown TM, Hernandez AF, Bittner V, et al; on behalf of
American Heart Association Get With the Guidelines Investigators. Predictors
of cardiac rehabilitation referral in coronary artery disease patients:
findings from the American Heart Associationís Get With the Guidelines
Program. J Am Coll Cardiol. 2009;54:515-521. 8. Thomas RJ, King M, Lui K,
Oldridge N, Pina IL, Spertus J. AACVPR/ACCF/AHA 2010 update: performance
measures on cardiac rehabilitation for referral to cardiac
rehabilitation/secondary prevention services: a report of the American
Association of Cardiovascular and Pulmonary Rehabilitation and the American
College of Cardiology Foundation/American Heart Association Task Force on
Performance Measures (Writing Committee to Develop Clinical Performance
Measures for Cardiac Rehabilitation). Circulation. 2010;122:1342-1350.
(Submitted by: American Association of Cardiovascular and Pulmonary
Rehabilitation)
| (Program: Inpatient Psychiatric Facilities Quality Reporting
Program ; MUC ID: E0647) |
- The proposed measures overlap with existing measures, as is noted in the
MAP rationale section.† Weíve been tracking them for our core measures for
some time.† We are concerned that there are differences in detail between the
different agencies proposing/enforcing these measures and would strongly urge
full harmonization.(Submitted by: Armstrong Institute for Patient Safety and
Quality)
- Facilities are required by CMS (CoPs) and TJC to provide a patient with
discharge information and instructions. This measure would duplicate a
regulatory requirement which is being met by facilities included in the IPF QR
program. The measure was not developed or tested in IPF settings and is not
designed for this setting. It includes elements (e.g. major procedures and
tests performed during inpatient stay, studies pending at discharge, etc.)
that are not relevant. The requirements include principal diagnosis at
discharge. For psychiatric patients, we are required to use patient-friendly
language and stating the ìprincipal diagnosisî is often not the most
clinically appropriate information to communicate. While we recognize the CMS
goal of measure alignment across similar programs, we do not think this is a
good candidate for this alignment because of the unique characteristics of the
patients cared for under the IPF PPS.(Submitted by: National Association of
Psychiatric Health Systems)
- [Pre-workgroup meeting comment] The specific elements contained in
this measure are not sensitive to the information needs of psychiatric
patients at discharge. The measure was developed for a different population
and needs to be reviewed for most appropriate elements and usability for
target population(Submitted by: National Association of Psychiatric Health
Systems)
- [Pre-workgroup meeting comment] The transition information given to
patients needs to be harmonized with other continuity of care measures already
required in the IPF QR program. Facilities routinely send information with
patients at the point of discharge. A review of current practice could support
the development/harmonization of this measure.(Submitted by: National
Association of Psychiatric Health Systems)
- [Pre-workgroup meeting comment] Patient instructions are clearly an
important aspect to continuity of care. Patient instructions must be written
in a language and manner understandable to the patient, empowering the patient
to continue appropriate care to address conditions. The measure is
prescriptive as to components, but there needs to be additional definitions as
to what is included in the component ìpatient instructionsî and the component
ìprincipal diagnosisî needs to be phrased as a condition to ensure
patient-centered language. NRI would support a patient instructions measure
that is harmonized with the HBIPS 6/7 measures that address the creation and
transmission of a continuing care plan, and incorporate patient-centered
language. NRI would also suggest additional exclusions for patients with
unplanned discharges and patients refusing aftercare. (Submitted by: National
Association of State Mental Health Program Directors Research Institute
(NRI))
| (Program: Inpatient Psychiatric
Facilities Quality Reporting Program ; MUC ID: E0648) |
- The proposed measures overlap with existing measures, as is noted in the
MAP rationale section.† Weíve been tracking them for our core measures for
some time.† We are concerned that there are differences in detail between the
different agencies proposing/enforcing these measures and would strongly urge
full harmonization.(Submitted by: Armstrong Institute for Patient Safety and
Quality)
- IPFs have had NQF-endorsed HBIPS-7 in place for almost 10 years as a
condition of The Joint Commission accreditation and, since the beginning of
the IPF QR program, as a CMS requirement for payment and public reporting. The
measure requires that specific information is transmitted to the next level of
care within 5 days. The HBIPS measure has a significant body of data that has
been collected through those years that has been very helpful in changing
practice in the field. Changing the measure now would erase all the useful
data that now exists. While the field has improved in compliance rates, there
is still room for significant improvement. HBIPS-7 has been found by the field
to contain the elements (reason for hospitalization, medications, discharge
diagnosis, and recommendations for continuing care plan) that are most
relevant for continuity for psychiatric patients. The timeframe of 5 days
(while many plans are transmitted sooner) allows the discharging facility to
submit a complete plan that reaches the post-discharge facility before the
patientís first appointment. The measure is required for all patients,
regardless of diagnosis, and is stratified for reporting by age. Measure E0648
has not been developed for or tested within IPFs, and is duplicative of a
measurement domain already being addressed. It requires information that is
not relevant to the population. While we recognize the CMS goal of measure
alignment across similar programs, we do not think this is a good candidate
for this alignment because of the unique characteristics of the patients cared
for under the IPF PPS. (Submitted by: National Association of Psychiatric
Health Systems)
- The Joint Commission appreciates the desire for development of an
overarching transition of care measure, and would be happy to discuss
potential harmonization. The Preliminary Decision (recommendation) for this
measure is Support. We would not be in favor of this preliminary
recommendation. We suggest that the designation category should be changed to
another decision category until such time that selection of a best in class
measure or a harmonized metric by an appropriate Standing Committee is
addressed and it is determined the measure to be implemented. (Submitted by:
The Joint Commission)
- [Pre-workgroup meeting comment] NRI sees this measure as competing
with the existing IPFQR measure HBIPS-7. The National Quality Forum defines a
competing measure as measures that address both the same focus and the same
target population. NQF clearly states that such duplicative measures and
those with similar but not identical specifications increase data collection
burden and create confusion or inaccuracy in interpreting performance results
for those who implement and use performance measures. Measure E0648 presents
major concerns, as it does not clearly state that all the components (detailed
in E0647) need to be covered in this measure. It is unclear if these are
considered paired measures. As noted above, information in patient
instructions needs to be patient-centered while information for a healthcare
provider may be more clinically specific. Additionally, the 24 hours
timeframe is too inflexible. It does not provide the necessary time for
certain clinical specialties to be available to the same extent during
weekends and holidays to complete the transition record. About half of the
193 free-standing hospitals that we work with do not have electronic health
records so the transition record would have to be developed by hand and
transmitted using secure procedures to protect patient information. (Submitted
by: National Association of State Mental Health Program Directors Research
Institute (NRI))
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0704)
|
- AdvaMed supports the MAP recommendation to conditionally support inclusion
of this outcome measure in the Hospital Inpatient Quality Reporting program.
The measure addresses important adverse outcomes that can cause harm to
patients and result in increased healthcare costs. Adoption of this measure
will result in increased use of evidence based treatments and therapies to
prevent serious and costly avoidable complications such as sepsis, heart
failure, deep vein thrombosis or other HACs. Pending NQF review of testing
data in a Medicare population, as well as an evaluation of whether this
measure should be adjusted for sociodemographic factors, implementation of
this measure in the Hospital IQR program can quickly lead to
improvements.(Submitted by: AdvaMed)
- AGS supports the NQFís actions on this measure which would focus on all
cause harm in patients during their acute episode of care. This would
encourage care coordination and work with post-acute care providers and might
encourage a focus on the geriatric hospital acquired conditions. Given the
criticism that disease-specific reporting is more actionable, we would counter
that this will encourage global approaches to safe patient care, rather than
what is sometimes an unhealthy focus on one condition to the exclusion of
others.(Submitted by: American Geriatrics Society)
- SHM has concerns for this hospital-level measure that seeks to capture the
amount of potentially avoidable complications for AMI patients. We note that
it is difficult to define the condition and associate complications
appropriately in a way that reflects actionable information for providers and
hospitals. Some of the data on complications may be difficult to collect,
particularly in the absence of fully interoperable EHR systems. Furthermore,
there is concern about whether certain complications are truly preventable and
that these measures may inadvertently penalize hospitals and providers for
complications outside their scope of control. SHM would also recommend further
clarification whether these measures would reflect inpatient stays only or be
inclusive of observation stays, which would be more comprehensive of hospital
care. (Submitted by: Society of Hospital Medicine)
- On behalf of Edwards Lifesciences, we appreciate the opportunity to
comment on the recommendations for the Measures Under Consideration (MUC) list
being reviewed by the Measure Applications Partnership (MAP). Edwards
Lifesciences is the global leader in the science of heart valves and
hemodynamic monitoring.Our technologies address large and growing patient
populations in which there are significant unmet clinical needs, such as
structural heart disease and advanced monitoring of the acutely ill. We
support the MAPís efforts to provide balanced, multi-stakeholder input to the
Department of Health and Human Services (HHS) on the selection of performance
measures for use in federal public reporting and performance-based payment
programs. We are pleased to offer detailed comments on several of the
important measures being considered this year, including providing input on
the MAPís deliberations and recommendations thus far. E0704 Proportion of
Patients Hospitalized with AMI that have a Potentially Avoidable Complication
(during the Index Stay or in the 30-day Post-Discharge Period) ñ Hospital
Inpatient Quality Reporting Edwards supports the MAP recommendation to
conditionally support inclusion of this outcome measure in the Hospital
Inpatient Quality Reporting program. The measure addresses important adverse
outcomes that can cause harm to patients and result in increased healthcare
costs. Adoption of this measure will result in increased use of evidence
based treatments and therapies to prevent serious and costly avoidable
complications such as sepsis, heart failure, deep vein thrombosis or other
HACs. Pending NQF review of testing data in a Medicare population, as well as
an evaluation of whether this measure should be adjusted for sociodemographic
factors, implementation of this measure in the Hospital IQR program can
quickly lead to improvements.(Submitted by: Edwards Lifeciences)
- GNYHA does not support this measure for the IQR program because it is
inappropriate for hospitals. The developerís rationale for this measure is:
ìAccountability for and measurement of PACs occurs at the practice, medical
group, provider system or purchaser/payer level, not for an individual
physicianís performance.î The developer did not contemplate applying this
measure to acute inpatient care because hospitals do not provide follow-up
care directly or manage care in the community or in residential facilities.
Rather, they are responsible for communicating clear post-discharge
instructions to the patient, linking patients with appropriate community-based
and residential providers, and ensuring the transmission of information about
the episode of care and discharge plans to those providers. Nonetheless, we
believe the first part of the measureóPACs during the index stayócould be
applicable to hospitals if it was modified by adding adequate risk adjustment.
As the developer notes, PACs during the index stay include those related to
the anchor condition, comorbidities, and patient safety failures. It is PACs
related to comorbidities that require risk adjustment because the distribution
of patients with comorbidities varies greatly among hospitals. In particular,
major teaching hospitals tend to treat patients with complex conditions at a
much higher rate than community hospitals. Therefore, to avoid systematic risk
to major teaching hospitals, the proportion of patients with comorbidities
must be factored into any measure of hospital-acquired conditions (HACs)
related to comorbidities. (Submitted by: Greater New York Hospital
Association)
- 5. NKF has concerns about excluding people with kidney failure who are on
dialysis from quality measures when there is no clinical reason to do so as
this removes accountability for delivering high quality care to complex
patients. As a result, NKF opposes the exclusion of dialysis patients from:
ï E0704 Proportion of Patients Hospitalized with AMI that have a Potentially
Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge
Period) ï E0705 Proportion of Patients Hospitalized with Stroke that have a
Potentially Avoidable Complication (during the Index Stay or in the 30-day
Post-Discharge Period) ï E0708 Proportion of Patients Hospitalized with
Pneumonia that have a Potentially Avoidable Complication (during the Index
Stay or in the 30-day Post-Discharge Period) Similar measures are used in the
hospital readmissions program that do not exclude patients on dialysis and as
a result have led to improvements in care coordination between dialysis
facilities and hospitals. NKF has concerns that approving these measures with
the exclusion will also lead to the exclusion of dialysis in the measures for
the hospital readmissions reduction program. Preventing the listed
complications in dialysis patients is possible with appropriate clinical care
and care coordination. Dialysis patients should receive the same quality of
care as other patients even though their kidney failure status renders their
care more complex. Cardiovascular outcomes and infections are the two leading
causes of hospitalizations in dialysis patients, with cardiovascular events as
the leading cause of mortality. A recent study- showed that the risk of
readmissions for hemodialysis patients could be reduced by 3.5 percent with
just one additional, meaningful visit with their nephrology practitioners
during the month of discharge. However, in order to act on this the
practitioner needs to receive accurate and complete discharge information from
the hospital in a timely manner. Proper care coordination within a
nephrologist and dialysis can also help hospitals avoid complications within
the 30 days of discharge window. Removing dialysis patients from these
measures may impede proper care coordination vital to reducing deaths and
re-hospitalizations for this population. For hospitals that treat a higher
number of dialysis patients than the average, we suggest using risk adjustment
in the measures rather than total exclusion in order to avoid penalizing
hospitals unfairly. Improving outcomes for people on dialysis requires
accountability and coordination across the patientís healthcare providers.
(Submitted by: National Kidney Foundation)
- Understanding and preventing harm to patients is of paramount importance
and Premier supports the concept of examining all harm including harm that is
detected post discharge. We are however concerned that this methodology has
not been vetted and tested. For many reasons it is difficult to gage harm
based on ICD-9 codes alone. In our own work we have found varying degrees of
sensitivity and specificity depending on the condition being examined. We
also feel it is quite difficult to separate out separate harm events from
events that are part of a causal chain. For example a pulmonary embolism
resulting in atrial fibrillation and respiratory failure is one event but
could be scored as three if one fails to recognize the causal connections
which is difficult to do in coded discharge summary data. Finally, it is
extremely difficult to determine preventability even with the entire clinical
record available. For this reason the Institute for Healthcare Improvement
does not advocate determining preventable events with its trigger tool, only
harm events. The term preventable event can be misleading. In summary these
measures are aspirational, but much more work needs to be done to understand
their accuracy and validity before incorporating these measures into federal
programs. (Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0705)
|
- AdvaMed supports the MAP recommendation for conditional support of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- AGS supports the NQFís actions on this measure which would focus on all
cause harm in patients during their acute episode of care. This would
encourage care coordination and work with post-acute care providers and might
encourage a focus on the geriatric hospital acquired conditions. Given the
criticism that disease-specific reporting is more actionable, we would counter
that this will encourage global approaches to safe patient care, rather than
what is sometimes an unhealthy focus on one condition to the exclusion of
others.(Submitted by: American Geriatrics Society)
- SHM has concerns for this hospital-level measure that seeks to capture the
amount of potentially avoidable complications for stroke patients. We note
that it is difficult to define the condition and associate complications
appropriately in a way that reflects actionable information for providers and
hospitals. Some of the data on complications may be difficult to collect,
particularly in the absence of fully interoperable EHR systems. Furthermore,
there is concern about whether certain complications are truly preventable and
that these measures may inadvertently penalize hospitals and providers for
complications outside their scope of control. SHM would also recommend further
clarification whether these measures would reflect inpatient stays only or be
inclusive of observation stays, which would be more comprehensive of hospital
care.(Submitted by: Society of Hospital Medicine)
- This measure, under consideration for the Hospital Inpatient Quality
Reporting (IQR) Program, evaluates the percent of adult population aged 18ñ65
years who were admitted to a hospital with stroke, were followed for one month
after discharge, and had one or more potentially avoidable complications
(PACs). The MAP recommends ìconditional supportî for this measure pending
expansion of the measure specifications to greater than 65 years old, and
successful testing and NQF endorsement of the measure with the expanded
population. The AANS and CNS do not support this measure. This measure looks
at a wide variety of hospital acquired conditions, but has no mechanism for
risk adjustment based upon patient co-morbidities or patient specific factors.
For example, a patientís risk of PAC increases based on the severity of
his/her complete stroke. Additionally, the measure requires more rigorous and
specific definitions for each PAC to be reported. For example, simply using
terms like "malignant hypertension" or "lung complication" is inadequate.
Until this all-cause harm measure more appropriately distinguishes between
patients, it should not be used for accountability purposes.(Submitted by:
American Association of Neurological Surgeons/Congress of Neurological
Surgeons)
- Itís difficult to fully evaluate this measure, since limited
specifications are provided, but we are very concerned that this measure is of
limited value for quality improvement and, at worst, could produce misleading
information. We urge the MAP not to support it for use in the Inpatient
Quality Reporting Program without substantial revision. We appreciate the
measureís patient focus, we are also concerned about attribution of the
measure, especially if it is to be used in determining payment. Since it
requires follow up for 1 month after discharge, multiple providers may be
involved in the patientís care. The underlying assumption that all of these
complications are indeed potentially avoidable is arguable; for some of these,
such as pneumonia, sepsis, GI bleeding, this may not be true. There is also
significant overlap among the categories of complications and we are skeptical
that they can be accurately implemented with standard definitions. For
example, respiratory failure (listed as related to stroke) might result from
pneumonia (listed as due to comorbidities), so how this complication would be
coded is unclear. Diabetic complications are listed in the ìdue to
comorbiditiesî category even though they are also included in the CMS
Healthcare Acquired Conditions (HAC) list (suggesting they might be in the
ìpatient safetyî category). We are concerned that clearly defining and
operationalizing many of the PACs is extremely difficult at best and very
prone to misclassification. For example, defining hypertensive encephalopathy
in stroke patients with cognitive deficits and in whom the physician is
allowing the blood pressure to be elevated for the first 48-72 hours would be
very challenging. It is also unclear how the PACs are considered in relation
to the patientís baseline or when their baseline is unknown. While we
recognize the importance of tracking and preventing potentially avoidable
complications in stroke patients, we would suggest choosing a smaller set of
stroke-related complications to better focus quality improvement efforts.
Since the CMS HACs are already defined and include important stroke-related
complications (e.g. pulmonary embolism, deep vein thrombosis,
catheter-associated urinary tract infection, falls, and pressure ulcers),
adding a limited number of other important stroke-related complications, e.g.,
hemorrhage and aspiration pneumonia, to this list would yield a much more
manageable and relevant set of PACs to measure and would provide information
that is more actionable for providers and more interpretable for consumers.
Finally, since those with existing comorbidities or disability are more likely
to experience complications, it is essential that this measure be properly
risk adjusted, preferably using a risk-adjustment model that incorporates
initial stroke score (e.g., NIHSS) and age, among other key variables.
(Submitted by: American Heart Association/American Stroke
Association)
- GNYHA does not support this measure for the IQR program because it is
inappropriate for hospitals. The developerís rationale for this measure is:
ìAccountability for and measurement of PACs occurs at the practice, medical
group, provider system or purchaser/payer level, not for an individual
physicianís performance.î The developer did not contemplate applying this
measure to acute inpatient care because hospitals do not provide follow-up
care directly or manage care in the community or in residential facilities.
Rather, they are responsible for communicating clear post-discharge
instructions to the patient, linking patients with appropriate community-based
and residential providers, and ensuring the transmission of information about
the episode of care and discharge plans to those providers. Nonetheless, we
believe the first part of the measureóPACs during the index stayócould be
applicable to hospitals if it was modified by adding adequate risk adjustment.
As the developer notes, PACs during the index stay include those related to
the anchor condition, comorbidities, and patient safety failures. It is PACs
related to comorbidities that require risk adjustment because the distribution
of patients with comorbidities varies greatly among hospitals. In particular,
major teaching hospitals tend to treat patients with complex conditions at a
much higher rate than community hospitals. Therefore, to avoid systematic risk
to major teaching hospitals, the proportion of patients with comorbidities
must be factored into any measure of HACs related to comorbidities. (Submitted
by: Greater New York Hospital Association)
- 5. NKF has concerns about excluding people with kidney failure who are on
dialysis from quality measures when there is no clinical reason to do so as
this removes accountability for delivering high quality care to complex
patients. As a result, NKF opposes the exclusion of dialysis patients from:
ï E0704 Proportion of Patients Hospitalized with AMI that have a Potentially
Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge
Period) ï E0705 Proportion of Patients Hospitalized with Stroke that have a
Potentially Avoidable Complication (during the Index Stay or in the 30-day
Post-Discharge Period) ï E0708 Proportion of Patients Hospitalized with
Pneumonia that have a Potentially Avoidable Complication (during the Index
Stay or in the 30-day Post-Discharge Period) Similar measures are used in the
hospital readmissions program that do not exclude patients on dialysis and as
a result have led to improvements in care coordination between dialysis
facilities and hospitals. NKF has concerns that approving these measures with
the exclusion will also lead to the exclusion of dialysis in the measures for
the hospital readmissions reduction program. Preventing the listed
complications in dialysis patients is possible with appropriate clinical care
and care coordination. Dialysis patients should receive the same quality of
care as other patients even though their kidney failure status renders their
care more complex. Cardiovascular outcomes and infections are the two leading
causes of hospitalizations in dialysis patients, with cardiovascular events as
the leading cause of mortality. A recent study- showed that the risk of
readmissions for hemodialysis patients could be reduced by 3.5 percent with
just one additional, meaningful visit with their nephrology practitioners
during the month of discharge. However, in order to act on this the
practitioner needs to receive accurate and complete discharge information from
the hospital in a timely manner. Proper care coordination within a
nephrologist and dialysis can also help hospitals avoid complications within
the 30 days of discharge window. Removing dialysis patients from these
measures may impede proper care coordination vital to reducing deaths and
re-hospitalizations for this population. For hospitals that treat a higher
number of dialysis patients than the average, we suggest using risk adjustment
in the measures rather than total exclusion in order to avoid penalizing
hospitals unfairly. Improving outcomes for people on dialysis requires
accountability and coordination across the patientís healthcare providers.
(Submitted by: National Kidney Foundation)
- Understanding and preventing harm to patients is of paramount importance
and Premier supports the concept of examining all harm including harm that is
detected post discharge. We are however concerned that this methodology has
not been vetted and tested. For many reasons it is difficult to gage harm
based on ICD-9 codes alone. In our own work we have found varying degrees of
sensitivity and specificity depending on the condition being examined. We
also feel it is quite difficult to separate out separate harm events from
events that are part of a causal chain. For example a pulmonary embolism
resulting in atrial fibrillation and respiratory failure is one event but
could be scored as three if one fails to recognize the causal connections
which is difficult to do in coded discharge summary data. Finally, it is
extremely difficult to determine preventability even with the entire clinical
record available. For this reason the Institute for Healthcare Improvement
does not advocate determining preventable events with its trigger tool, only
harm events. The term preventable event can be misleading. In summary these
measures are aspirational, but much more work needs to be done to understand
their accuracy and validity before incorporating these measures into federal
programs. (Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] (Submitted by:
AdvaMed)
| (Program: Inpatient Quality Reporting Program ; MUC ID: E0708)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- AGS supports the NQFís actions on this measure which would focus on all
cause harm in patients during their acute episode of care. This would
encourage care coordination and work with post-acute care providers and might
encourage a focus on the geriatric hospital acquired conditions. Given the
criticism that disease-specific reporting is more actionable, we would counter
that this will encourage global approaches to safe patient care, rather than
what is sometimes an unhealthy focus on one condition to the exclusion of
others.(Submitted by: American Geriatrics Society)
- In the dually eligible population the rate of hospitalization with
pneumonia is higher than in the general population or the Medicare population.
This places greater importance on this measure(Submitted by: AmeriHealth
Caritas)
- SHM has concerns for this hospital-level measure that seeks to capture the
amount of potentially avoidable complications for pneumonia patients. We note
that it is difficult to define the condition and associate complications
appropriately in a way that reflects actionable information for providers and
hospitals. Some of the data on complications may be difficult to collect,
particularly in the absence of fully interoperable EHR systems. Furthermore,
there is concern about whether certain complications are truly preventable and
that these measures may inadvertently penalize hospitals and providers for
complications outside their scope of control. SHM would also recommend further
clarification whether these measures would reflect inpatient stays only or be
inclusive of observation stays, which would be more comprehensive of hospital
care. (Submitted by: Society of Hospital Medicine)
- GNYHA does not support this measure for the IQR program because it is
inappropriate for hospitals. The developerís rationale for this measure is:
ìAccountability for and measurement of PACs occurs at the practice, medical
group, provider system or purchaser/payer level, not for an individual
physicianís performance.î The developer did not contemplate applying this
measure to acute inpatient care because hospitals do not provide follow-up
care directly or manage care in the community or in residential facilities.
Rather, they are responsible for communicating clear post-discharge
instructions to the patient, linking patients with appropriate community-based
and residential providers, and ensuring the transmission of information about
the episode of care and discharge plans to those providers. Nonetheless, we
believe the first part of the measureóPACs during the index stayócould be
applicable to hospitals if it was modified by adding adequate risk adjustment.
As the developer notes, PACs during the index stay include those related to
the anchor condition, comorbidities, and patient safety failures. It is PACs
related to comorbidities that require risk adjustment because the distribution
of patients with comorbidities varies greatly among hospitals. In particular,
major teaching hospitals tend to treat patients with complex conditions at a
much higher rate than community hospitals. (Submitted by: Greater New York
Hospital Association)
- 5. NKF has concerns about excluding people with kidney failure who are on
dialysis from quality measures when there is no clinical reason to do so as
this removes accountability for delivering high quality care to complex
patients. As a result, NKF opposes the exclusion of dialysis patients from:
ï E0704 Proportion of Patients Hospitalized with AMI that have a Potentially
Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge
Period) ï E0705 Proportion of Patients Hospitalized with Stroke that have a
Potentially Avoidable Complication (during the Index Stay or in the 30-day
Post-Discharge Period) ï E0708 Proportion of Patients Hospitalized with
Pneumonia that have a Potentially Avoidable Complication (during the Index
Stay or in the 30-day Post-Discharge Period) Similar measures are used in the
hospital readmissions program that do not exclude patients on dialysis and as
a result have led to improvements in care coordination between dialysis
facilities and hospitals. NKF has concerns that approving these measures with
the exclusion will also lead to the exclusion of dialysis in the measures for
the hospital readmissions reduction program. Preventing the listed
complications in dialysis patients is possible with appropriate clinical care
and care coordination. Dialysis patients should receive the same quality of
care as other patients even though their kidney failure status renders their
care more complex. Cardiovascular outcomes and infections are the two leading
causes of hospitalizations in dialysis patients, with cardiovascular events as
the leading cause of mortality. A recent study- showed that the risk of
readmissions for hemodialysis patients could be reduced by 3.5 percent with
just one additional, meaningful visit with their nephrology practitioners
during the month of discharge. However, in order to act on this the
practitioner needs to receive accurate and complete discharge information from
the hospital in a timely manner. Proper care coordination within a
nephrologist and dialysis can also help hospitals avoid complications within
the 30 days of discharge window. Removing dialysis patients from these
measures may impede proper care coordination vital to reducing deaths and
re-hospitalizations for this population. For hospitals that treat a higher
number of dialysis patients than the average, we suggest using risk adjustment
in the measures rather than total exclusion in order to avoid penalizing
hospitals unfairly. Improving outcomes for people on dialysis requires
accountability and coordination across the patientís healthcare providers.
(Submitted by: National Kidney Foundation)
- Understanding and preventing harm to patients is of paramount importance
and Premier supports the concept of examining all harm including harm that is
detected post discharge. We are however concerned that this methodology has
not been vetted and tested. For many reasons it is difficult to gage harm
based on ICD-9 codes alone. In our own work we have found varying degrees of
sensitivity and specificity depending on the condition being examined. We
also feel it is quite difficult to separate out separate harm events from
events that are part of a causal chain. For example a pulmonary embolism
resulting in atrial fibrillation and respiratory failure is one event but
could be scored as three if one fails to recognize the causal connections
which is difficult to do in coded discharge summary data. Finally, it is
extremely difficult to determine preventability even with the entire clinical
record available. For this reason the Institute for Healthcare Improvement
does not advocate determining preventable events with its trigger tool, only
harm events. The term preventable event can be misleading. In summary these
measures are aspirational, but much more work needs to be done to understand
their accuracy and validity before incorporating these measures into federal
programs. (Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program: Medicare Shared Savings Program; MUC ID:
E0711) |
- We support this measure because it promotes outcomes-based,
patient-centered care. We agree with NQF's comment that this measure should
align with 0712, Use of PHQ-9. (Submitted by: Press Ganey
Associates)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: E1406)
|
- How will a look back be done? This may be difficult to measure.(Submitted
by: Armstrong Instititue for Patient Safety and Quality)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: E1507)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
| (Program: Medicare Shared
Savings Program; MUC ID: E1523) |
- The ACS supports the MAP Clinician Workgroupís recommendation ofcontinued
development of this measure as a composite measure for the MSSP. This measure
is reportable by vascular surgeons and general surgeons who perform abdominal
procedures. (Submitted by: The American College of Surgeons)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: E1523) |
- The ACS supports the MAP Clinician Workgroupís recommendation of "support"
of this measure for inclusion in PQRS, Physician Compare, and VBPM. This
measure is reportable by vascular surgeons and general surgeons who perform
abdominal procedures. (Submitted by: The American College of
Surgeons)
| (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: E1553) |
- This measure may add value, since this blood pressure in adolescents may
be under-measured at present. It may be more likely to be measured in
populations of children with obesity, but certainly missed in others. It is
unclear what the intended outcome is, if BP is measured only once in a
measurement year. It appears that the measure would only apply to adolescents
turning 18 years old in the measurement period ñ not to all adolescents
seeking medical care during the measurement period. It is uncertain that
measuring will lead to any improvement in outcome without an action tied to
it. There is the possibility of preventative cardiovascular care as an
adolescent ages into adulthood and improved cardiac/neuro function later in
life and decreased consumption of resources, but it is hard to know how that
would work based on a single measure of BP. Perhaps this should be part of any
wellness screening and should be measured and reported. If the screening takes
place before age 18 the guidelines of ìThe fourth report on the diagnosis,
evaluation, and treatment of high blood pressure in children and adolescentsî
(published in Pediatrics, 2004) should be used. (Submitted by: American
Academy of Pediatrics)
| (Program: PPS-Exempt Cancer Hospital
Quality Reporting Program ; MUC ID: E1641) |
- TAHCH recommends documentation of treatment preferences within 5 days for
patients on hospice instead of 7 days. Our rationale is that hospices are
currently required by Medicare Conditions of Participation to document a
comprehensive assessment within 5 days of admission to hospice and this
assessment includes treatment preferences. Ideally, patients would not even
be referred to hospice services without documentation of treatment
preferences, but this may not be realistic for all hospitals. (Submitted by:
Texas Association for Home Care & Hospice )
- This measure, under consideration for the PPS-exempt Cancer Hospital
Quality Reporting Program, evaluates the percentage of patients with chart
documentation of preferences for life sustaining treatments. The MAP
ìconditionally supportsî this measure pending clarifications and updates to
the measure specifications with a review and endorsement by the relevant NQF
Standing Committee of these updates. Members of the workgroup raised specific
concerns about this measure. For one, they want to see clarification of the
definition of seriously ill. AAHPM notes that the National Consensus Project
for Quality Palliative Care has developed Clinical Practice Guidelines for
Quality Palliative Care, which includes a definition of palliative care.1
Other critics of this measure expressed the need to broaden the denominator to
include patients followed by a palliative care or supportive care team, not
just those in a palliative care unit. Still others felt the measure should be
completely re-specified so that it applies to all patients. While AAHPM
supports employing the broadest definition possible to comprehensively capture
the patient population appropriate for palliative care, there is also a
critical need to quickly fill this measure gap. Given the need to start
somewhere and the fact that this measure has already been carefully vetted and
endorsed by the NQF, we recommend that the measure be adopted as is with the
goal of expanding the denominator in the future. In response to concerns that
performance is already high on this measure, AAHPM believes that the
importance of this measure to patients warrants efforts to raise the bar even
higher and aim for 100% compliance.(Submitted by: American Academy of Hospice
and Palliative Medicine)
- This measure, under consideration for the PPS-exempt Cancer Hospital
Quality Reporting Program, evaluates the percentage of patients with chart
documentation of preferences for life sustaining treatments. The MAP
ìconditionally supportsî this measure pending clarifications and updates to
the measure specifications with a review and endorsement by the relevant NQF
Standing Committee of these updates. Members of the workgroup raised
specific concerns about this measure. For one, they want to see clarification
of the definition of seriously ill. AAHPM notes that the National Consensus
Project for Quality Palliative Care has developed Clinical Practice Guidelines
for Quality Palliative Care, which includes a definition of palliative care.
Other critics of this measure expressed the need to broaden the denominator to
include patients followed by a palliative care or supportive care team, not
just those in a palliative care unit. Still others felt the measure should be
completely re-specified so that it applies to all patients. While AAHPM
supports employing the broadest definition possible to comprehensively capture
the patient population appropriate for palliative care, there is also a
critical need to quickly fill this measure gap. Given the need to start
somewhere and the fact that this measure has already been carefully vetted and
endorsed by the NQF, we recommend that the measure be adopted as is with the
goal of expanding the denominator in the future. In response to concerns that
performance is already high on this measure, AAHPM believes that the
importance of this measure to patients warrants efforts to raise the bar even
higher and aim for 100% compliance.(Submitted by: AAHPM)
- Position: Do not adopt this measure. Relevance: Documentation of
patient preferences regarding life-extending treatment is extremely important
in delivering patient-centered cancer care. Our palliative care services
routinely engage in these discussions with patients and their caregivers.
However, this measure, as written, has limited relevance for our patient
population. This measure is written to address palliative care delivery in an
acute hospital setting and includes patients with a 1+ day length of stay on a
palliative care service. Yet, a very small subset of the Cancer Centers has a
dedicated inpatient palliative care unit. Moreover, most palliative care at
the Cancer Centers is delivered in the outpatient setting. This measure would
be strengthened by being expanded to include outpatient palliative care.
Additionallyóand more importantlyóend of life discussions should not be
delayed until death is imminent. For patients with advanced cancer diagnosis,
in particular, these discussions should begin during treatment planning and be
revisited periodically throughout treatment and if the patientís health status
worsens. In particular, the initiation of an acute inpatient stay should
warrant a review of these preferences, confirmation of elected surrogate, and
discussion of any new clinical information that would impact the patientís
clinical options and, therefore, achievable goals. The National Comprehensive
Cancer Network (NCCN) recommends initiating advance care planning for patients
with a life expectancy of one year or less.1 Again, this measure would be
greatly strengthened by being expanded to include documentation of treatment
preferences among patients with advanced cancer that are undergoing active
cancer treatment. We encourage CMS to delay consideration of this measure
until it has been revised (or an alternate measure has been developed) to be
more relevant for the Cancer Centers. If adopted, we request clarification to
better define the intended denominator population for this measure (e.g., is
this measure applicable to patients that are not admitted to a dedicated
palliative care unit? If so, how would these patients be identified via
claims data?) . Usability: The ADCC recognizes the importance of documenting
patient preferences regarding life-extending treatment, particularly for
patients with advanced disease. The Cancer Centers have ongoing initiatives
to ensure that these discussions occur and to improve documentation of those
discussions. As noted above, only two Cancer Centers have dedicated inpatient
palliative care units, which limits the scope of applicability and quality
improvement opportunity for this measure when applied to our care settings.
Also, as noted above, a broader measure that includes outpatient palliative
care as well as oncology care for patients with advanced cancer would offer
greater opportunity to improve care at the Cancer Centers. CMS may find it
beneficial to adopt this measure for community-based oncology care where care
delivery is not routinely integrated and where barriers exist to receiving
palliative care services. No other measures in the PCHQR program address
this aspect of patient care. Feasibility: Fully electronic capture of
treatment ìdiscussionsî with patients may prove to be challenging and would
create unnecessary burden for successful reporting. If adopted, the ADCC
requests application of a sampling methodology to reduce unnecessary reporting
burden. (Submitted by: Alliance of Dedicated Cancer
Centers)
- The Center to Advance Palliative care urges MAP to unconditionally support
this measure for inclusion into the PPS Exempt Cancer Hospital Quality
Reporting Program. This measure addresses a key measure gap, and will improve
care and reduce harm for the health systemís sickest, most vulnerable
patients. Indeed, the Hospital Workgroup notes the importance of this
measure, and that this measure addresses the critical program objective of the
PPS-Exempt Cancer HQRP. Its only stated reasons for conditionally supporting
the measure are that the definition of serious illness lacks clarity, and that
the denominator is too narrow. Neither of these reasons is valid. Clarity in
a quality measure is important as it enables the measure to be scientifically
valid. This measure has been endorsed by NQF, one of the most respected
bodies in measure endorsement, and has thus already been determined to be
scientifically valid. It is not the charge of the MAP hospital workgroup to
vet individual measures for validity, and indeed the MAP does not have the
time or resources to undertake this effort. As to the denominator, the
workgroup is mistaken in its assertion that the denominator only covers those
individuals in a palliative care unit. The denominator includes those
followed by a palliative care team, and thus the recommendation that it be
broadened to cover this population is moot. Misinterpretation of the
denominator notwithstanding, the argument that a denominator should be
expanded to cover (and ultimately benefit) more people is not an argument for
why the measure shouldnít be utilized in the currently-specified population.
We strongly urge the MAP to reconsider its position on this measure.
Honoring treatment preferences is a crucial aspect of not only good care, but
ethical care. It is well documented that patient preferences are often not
elicited and followed, and indeed it was the recommendation of the recent IOM
report that measures related to patient preferences should be developed and
implemented by payers and those involved in the reporting of healthcare
quality. See Improving Quality and Honoring Individual Preferences Near the
End of Life, IOM 2014. As CMS is both a leader in setting healthcare standards
and a government entity charged with administering its authority for the
benefit of its citizens, it is essential that CMS adopt measures like this,
that are NQF endorsed, support alignment across programs, and address a
critically important aspect of care. (Submitted by: Center to Advance
Palliative Care)
- The National Coalition for Hospice and Palliative Care (Coalition)
strongly recommends this Measure, E1641, Hospice and Palliative Care,
Treatment Preferences be approved by MAP and CMS. This measure is NQF
endorsed and went through all of the prescribed and extremely thorough steps
including field testing. NQF/MAP has acknowledged there are serious gaps in
quality measurement in this area and this measure would be of great value to
the measure set. There is wide-spread support throughout the hospice and
palliative care provider community for this measure as it is the cornerstone
for the provision of all health care in the US ñ honoring (and documenting)
the patientís treatment preferences. MAP noted that the definition of
ìseriously ill patientî required additional clarification. However, MAP has
the definition provided in the measure specifications which has been agreed to
and is used by the provider community and in major scientific and medical
publications without any dispute. There is no lack of definition or clarity
in this definition. Additionally, MAP raised another concern related to the
patient denominator being too narrowly defined. MAP has misunderstood the
patient denominator as being too narrowly defined as the measure includes all
patients followed by a palliative care team and does not require inpatient
status. The Institute of Medicine report, released this fall, Dying in
America, Improving Quality and Honoring Individual Preferences Near the End of
Life has recommended that additional quality measures are needed in palliative
care and for patients with serious illness and that documenting patient
preference for treatment is essential to providing quality care to people with
serious illness. The IOM strongly recommended that payors should utilize
quality measures to document treatment preferences. There is strong evidence
that implementing this measure would lead to improved patient outcomes and
improved patient and family satisfaction with the health care system. The
National Coalition is comprised of the leading hospice and palliative care
organizations dedicated to advancing care of patients and families living with
serious and often life-limiting conditions. The organizations that form the
Coalition represent more than 4,800 physicians, 11,000 nurses, 5,000
professional chaplains, several thousand social workers, researchers, 2,000
hospital palliative care programs, and several thousand hospices throughout
the nation caring for millions of patients with serious illness. Members of
our Coalition include the American Academy of Hospice and Palliative Medicine,
Association of Professional Chaplains, Center to Advance Palliative Care,
Hospice and Palliative Nurses Association, National Hospice and Palliative
Care Organization, National Palliative Care Research Center and the Social
Work Hospice and Palliative Care Network. Our combined membership represents
the team based approach to hospice and palliative care which is
family-centered and includes, at a minimum, a team of doctors, nurses, home
health aides, social workers, chaplains, and trained volunteers. The
Coalition strongly recommends NQF/MAP approve/support this measure, E1641,
Hospice and Palliative Care, Treatment Preferences without any further delay.
(Submitted by: National Coalition for Hospice and Palliative
Care)
- [Pre-workgroup meeting comment] Position: The ADCC does not support
the adoption of this measure for the PCHQR program. Would addition of the
measure add value to the program measure set? Only three of the eleven centers
have an inpatient palliative care unit, limiting the scope of application for
this measure. What is the measureís potential to improve patient outcomes?
Documentation of patient preferences regarding life-extending treatment is
extremely important in delivering patient-centered cancer care. Our
palliative care services routinely engage in these discussions with patients
and their caregivers. However, the centers feel that there is limited
potential to improve patient outcomes through the application of this measure
because it only applies to three centers. Would use of the measure create
undue data collection or reporting burden? Yes, fully electronic capture of
treatment ìdiscussionsî with patients may prove to be challenging and would
create unnecessary burden for successful reporting. If adopted for our
program, we would request that a sampling approach be adopted. Is there a
better measure available or does a measure already in the program set address
a particular program objective? No. (Submitted by: Alliance of Dedicated
Cancer Centers)
| (Program: Inpatient Psychiatric
Facilities Quality Reporting Program ; MUC ID: E1656) |
- The Joint Commission appreciates the support for this measure for the
Inpatient Psychiatric Facility setting. Of note is the fact that this measure
was developed to use in all care settings, and The Joint Commission would urge
consideration for adoption in the Hospital Inpatient Quality Reporting Program
and other CMS program settings as well.(Submitted by: The Joint
Commission)
- Screening for alcohol and tobacco is pretty standard at our facility for
patients admitted with psychiatric disorders.† These can be life-saving
interventions and should be encouraged.† Many of our patients are treated for
one or both during their inpatient stay.† However, we would worry that these
mandates would translate into enforced use of screening tools and/or† ìbrief
interventionsî (not defined here) that are not valid, are ineffective,
etc.†(Submitted by: Armstrong Institute for Patient Safety and
Quality)
- [Pre-workgroup meeting comment] The rationale for including tobacco
dependence interventions during a psychiatric hospitalization is compelling.
Tobacco use is the leading cause of premature disease and death in the United
States, responsible for almost half a million deaths and approximately $150
billion in added healthcare costs each year.[1] Moreover, it is a primary
driver of hospitalizations for cancers, stroke, cardiovascular and respiratory
diseases, and pregnancy and newborn complications. Tobacco use also interferes
with recovery and contributes to delayed bone and wound healing, infection,
and other post-operative complications. Finally, tobacco use is highly
prevalent among individuals with psychiatric disorders. A number of
epidemiologic and other studies have highlighted the high prevalence of
smoking among patients with psychiatric disorders, with most of these studies
documenting rates of smoking at least double the rate among the overall
population of adults in the United States. People with mental illness and/or
substance use disorders smoke at rates two to four times higher than the
overall adult population in the United States.[2] Hospitalizations are an
ideal time to assist smokers to quit. Every hospital in the United States must
provide a smoke-free environment if it is to be accredited by The Joint
Commission. And, hospitals across the nation are increasingly implementing
smoke-free campus policies. As a result, every hospitalized smoker is
temporarily housed in a smoke-free environment. In this environment, they may
be more motivated to quit than at any other time and that motivation may be
enhanced because their hospitalization was caused or made worse by smoking. In
addition, if a hospitalized smoker is offered and uses cessation medication to
manage withdrawal symptoms and has a positive experience, s/he may be more
likely to continue using that medication to permanently quit after discharge.
Importantly, the U.S. Department of Health and Human Services Public Health
Service Clinical Practice Guideline, Treating Tobacco Use and Dependence 2008
Update[3] (The Guideline) emphasizes that a hospitalization presents an
unequaled opportunity to promote tobacco cessation and urges such
evidence-based interventions be delivered to every hospitalized smoker. The
Guideline provides specific actions regarding assisting hospitalized patients
who smoke to quit. Tobacco users have higher hospitalization rates than those
who do not use tobacco and higher rates of readmission post-discharge.
However, most hospitals have not placed a high priority on systematically
identifying smokers, recording their smoking status, offering evidence-based
assistance in quitting, and following up after discharge. [1]. U.S. Department
of Health and Human Services. The Health Consequences of Smoking ó50 Years of
Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health Promotion, Office on
Smoking and Health, 2014.) [2]. Center for Behavioral Health Statistics and
Quality. (2013, February 5). The National Survey on Drug Use and Health
(NSDUH) Report: Smoking and mental illness. Rockville, MD: Substance Abuse and
Mental Health Services Administration. [3]. Fiore MC, Jaen CR, Baker TB, et
al. Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S.
Department of Health and Human Services, U.S. Public Health Service; 2008.
(Submitted by: University of Wisconsin School of Medicine and Public Health
Center for Tobacco Research and Intervention)
- [Pre-workgroup meeting comment] This measure addresses the
continuation of treatment for tobacco users. A caution needs to be given in
the application of the measure as stated and defined for general primary care
practices. In psychiatric care settings, tobacco use is a secondary concern.
As such concern needs to be given to the all-inclusive behavioral healthcare
treatment approaches meeting the intent of outpatient counseling ìprovided.î
Since the tobacco use was not the primary focus of the psychiatric hospital
stay, the focus of the referral would be for the primary psychiatric
condition. The hospital may suggest that the outpatient provider address these
additional issues, but may not be prescriptive of treatments; whereas the
hospital is likely to be prescriptive of treatments for the primary
psychiatric reason for the hospital stay. There are also many instances where
hospitals cannot arrange an appointment date but can arrange a link to a
provider. These hospitals are negatively impacted by the measure and
consideration should be given to arranging a referral absent a specific
appointment date. (Submitted by: National Association of State Mental Health
Program Directors Research Institute (NRI))
| (Program: PPS-Exempt Cancer Hospital Quality Reporting Program ;
MUC ID: E1659) |
- Position: Adopt with modifications and sampling, as described below.
Relevance: Influenza vaccination is an important component of federal and
state public health policy. As the ADCC solely cares for cancer patientsóa
particularly vulnerable populationóvaccination of our patients is important.
Of note, many of our patients receive influenza vaccinations from their
employer or primary care provider. We recommend that appropriate attention
be given to facilities, including the Cancer Centers, with patient populations
that deviate from the tested/studied cohorts. Adjustments should be made to
the specifications in order to provide accurate representations of the
measured value. For example, the MAP specified two exclusions, which the ADCC
supports: ï Patients receiving anti-B-cell antibodies, such as Rituximab; and,
ï Patients receiving intensive chemotherapy, such as induction or
consolidation chemotherapy. Additionally, some Cancer Centers have large HSC
transplant populations. While lifelong influenza immunization is recommended
for these patients, their immune system must recover before immunizations can
be effective. Therefore, the recommendation is to wait six months
post-transplant before immunizing against the flu.2 Performing such
surveillance would not be beneficial for this cohort of patients, as the
majority would not be candidates for immunization. Otherwise, patients who do
not fall within the listed and suggested exclusions are expected to benefit
from this measure as it has the potential to limit influenza infection rates.
This measure is written to apply to inpatient discharges only. However, as
most of our care is delivered in the outpatient setting, this measure would be
strengthened by being expanded to include patients seen in our clinics.
Usability: The ADCC recognizes the importance of influenza vaccination as a
public health policy. As noted above, our vulnerable patient population has
much opportunity to benefit from influenza vaccination. Of note, the majority
of HSC transplant patients would not be candidates for immunization, so
influenza immunization surveillance would not benefit this cohort of patients.
This measure is relevant for other ADCC patients, however. As noted above, a
broader measure that includes influenza screening in the outpatient setting
would offer greater opportunity to improve care at the Cancer Centers. No
other measures in the PCHQR program address this aspect of patient care.
Feasibility: Fully electronic capture of the numerator, denominator, and
inclusion/exclusion criteria may prove to be challenging and would create
unnecessary burden for successful reporting. If adopted, the ADCC requests
application of a sampling methodology to reduce unnecessary reporting burden.
(Submitted by: Alliance of Dedicated Cancer Centers)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] Position: The ADCC supports the
inclusion of this measure in the PCHQR program. However, the centers feel that
a target population should be clearly identified and additional exclusion
categories applied to the measure. Would addition of the measure add value to
the program measure set? Current patient exclusions consist of the following;
1. Patients who expire prior to hospital discharge and patients with an organ
transplant during the current hospitalization; 2. Patients for whom
vaccination was indicated, but supply had not been received by the hospital
due to problems with vaccine production or distribution; 3. Patients who have
a length of stay greater than 120 days; 4. Patients who are transferred or
discharged to another acute care hospital; and 5. Patients who leave Against
Medical Advice (AMA). Per the recommendations of IDSA (Infectious Diseases
Society of America) the following should also be exclusions which are
especially pertinent to the cancer patient population and would add value to
our centers; ï Patients receiving anti-B-cell antibodies (such as rituximab);
and ï Patients receiving INTENSIVE CHEMOTHERAPY such as that for induction or
consolidation. What is the measureís potential to improve patient outcomes?
Some of our centers have large HSC transplant populations. While lifelong
influenza immunization is recommended for these patients, their immune system
must recover before immunizations can be effective. Therefore the
recommendation is to wait 6 months post-transplant before immunizing against
the flu (Dykewicz, Clare A. "Guidelines for preventing opportunistic
infections among hematopoietic stem cell transplant recipients: focus on
community respiratory virus infections." Biology of Blood and Marrow
Transplantation 7.12 (2001): 19S-22S.). Performing such surveillance would not
be beneficial for this cohort of patients as the majority would not be
candidates for immunization. Otherwise, patients who do not fall within the
listed and suggested exclusions are expected to benefit from this measure as
it has potential to limit influenza infection rates. Would use of the measure
create undue data collection or reporting burden? Some of the centers stated
that at the current time point prevalence audits for the vaccination screening
process are done; however, numerator/denominators are not collected regularly
and exclusions have not been thoroughly applied according to stratifications
listed within quality measure specifications. Is there a better measure
available or does a measure already in the program set address a particular
program objective? The ADCC does not have suggestions for any other measure(s)
to replace #1659. (Submitted by: Alliance of Dedicated Cancer
Centers)
| (Program: Inpatient Psychiatric Facilities Quality
Reporting Program ; MUC ID: E1663) |
- Brief intervention (and screening) is likely insufficient in this
circumstance. The best data suggest that. Instead, anyone with a mental
health condition should have alcohol and drugs assessed and then have
intervention if needed (likely more than brief) and integrated into their
mental health care. Screening and brief intervention is a preventive service.
In this case, the issue is not prevention, rather it is appropriate treatment
of a mental health condition. Brief intervention should be considered
insufficient though perhaps better than nothing.(Submitted by: Boston Medical
Center/Boston University)
- The Joint Commission appreciates the support for this measure for the
Inpatient Psychiatric Facility setting. Of note is the fact that this measure
was developed to use in all care settings, and The Joint Commission would urge
consideration for adoption in the Hospital Inpatient Quality Reporting
Program and other CMS program settings as well.(Submitted by: The Joint
Commission)
- Inpatient measures seem to count for very little in this measure. It seems
to require referral to outpatient counseling for interested patients. How
available is this in underserved areas?(Submitted by: Armstrong Institute for
Patient Safety and Quality)
- The SUB measure set from which E1663 is drawn was developed and tested to
be a global population measure. When SUB-1 was adopted for the IPF QR program
last year, we made the point that assessing patients for alcohol use was
something routinely done by psychiatric hospitals, and is included as a
component of a much more thorough assessment of all drugs of abuse in
NQF-endorsed HBIPS-1. We took the position that the addition of a validated
tool for alcohol use alone, designed as a general population screen, was not
clinically helpful. The screening measure identifies only a certain level of
alcohol behavior and patients treated in a psychiatric hospital generally fall
into much higher risk categories than are identified by population screens.
The measure was only validated (and therefore required) for patients 18 years
of age or older. This excludes a significant group of patients who show
substantial alcohol misuse at much younger ages, a population included in
HBIPS-1. Feedback from the field during the last year supports this
positionóthere is no value-added in using a validated screen for risky alcohol
behavior. It is also duplicative of the TJC-required HBIPS-1 measure. The
measures proposed in the 2014 set extend the SUB measures to include brief
intervention. There has been significant discussion in the literature about
the usefulness of the brief intervention and the appropriate populations to
whom they should be applied (Saitz, Journal of the American Medical
Association Aug.6, 2014 and accompanying editorial ìBack to the Drawing Board
by Ralph Hingson of the National Institute on Alcohol Abuse and Alcoholism and
Wilson Compton, MD of the National Institute on Drug Abuse.) Based on our
concern about the implementation of SUB-1, we also recommend that the
usefulness of adding additional SUB measures be reconsidered. Brief
interventions are not the clinically recommended approach to dealing with the
level of alcohol abuse that requires treatment in psychiatric hospitals.
(Submitted by: National Association of Psychiatric Health
Systems)
- [Pre-workgroup meeting comment] This measure addresses the
continuation of care when a condition has been identified (as in the SUB-1
measure used by the IPFQR). NRI agrees that inpatient hospital stays are a
good opportunity to provide intervention to patients regarding their unhealthy
alcohol use. However, a larger portion of patients presenting for inpatient
psychiatric care have a co-occurring substance use diagnosis, not simply
unhealthy alcohol use. For these patients, more intensive substance use
treatments must be provided; however we recognize that is not the intent of
this measure. Should CMS wish to adopt this measure, we suggest that a
modification to the definition of brief intervention be provided to include
more intensive interventions. CMS should also consider a modification to the
SUB-1 measure to address the issue that a brief intervention may not be the
optimal intervention for persons identified with alcohol disorders.
(Submitted by: National Association of State Mental Health Program Directors
Research Institute (NRI))
| (Program: PPS-Exempt Cancer Hospital Quality Reporting
Program ; MUC ID: E1716) |
- Position: Adopt with modifications, as described below. Relevance: In
the hospital setting, MRSA can cause life-threatening pneumonia, bloodstream
infections, and surgical site infections. MRSA control aligns with the
National Quality Strategy priority to make care safer by reducing harm caused
in the delivery of care. As the ADCC solely cares for cancer patients, who
may be particularly vulnerable to MRSA infection, effective MRSA control is an
essential component of patient safety. However, many MRSA carriers have no
active infection, and this measure does not differentiate between MRSA
colonization and MRSA infection. The ADCC favors adoption of measures that
focus on improved infection control practices, rigorous antibiotic stewardship
programs, and decreased incidence of HAI, rather than surveillance measures
such as this one. Because cancer patients may be at higher risk for MRSA
infection than others, the ADCC agrees with the MAPís proposed stratification
for cohorts of cancer patients (i.e., BMT, hematologic, and solid tumor).
Usability: The ADCC recognizes the importance of effective MRSA control in
our hospitals. The Cancer Centers have adopted rigorous infection control
protocols to minimize MRSA transmission and to closely track active
infections. Duplicative reporting of MRSA colonization through the LabID
offers questionable value to the PCHQR, particularly since our facilities are
currently reporting hospital-wide blood-stream infections via 0139-National
Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection
(CLABSI) Outcome Measure. There is some overlap between these two measures.
Feasibility: As written, this measure requires manual tracking of LabID
events. Moreover, duplicative reporting does not add value to patient care,
but creates unnecessary burden on centers already reporting MRSA infections
via 0139-National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome Measure. (Submitted by: Alliance of
Dedicated Cancer Centers)
- [Pre-workgroup meeting comment] Position: The ADCC agrees with the
direction of this measure but believe that stratifications for cohorts of
cancer patients (BMT, Hematologic, and Solid tumor) should be applied. We
recommend that the measure steward be contacted with our concerns to make
amenable edits. Would addition of the measure add value to the program
measure set? ADCC facilities currently report all institute-wide CLABSIs
based on NHSN surveillance definitions. We appreciate the importance of this
measure, but believe that duplicative reporting through the LabID would not
add value to the PCHQR program. What is the measureís potential to improve
patient outcomes? Lower transmission rates most likely indicate regular
practice of activities that would break transmission (e.g. hand hygiene,
disinfection, etc.). These are already reported in the NHSN program. Would use
of the measure create undue data collection or reporting burden? One concern
of the ADCC is that our facilities are currently reporting all institute-wide
CLABSI cases based on NHSN surveillance definitions, and additional reporting
of Lab-ID events would create duplicative burden. Is there a better measure
available or does a measure already in the program set address a particular
program objective? As noted above, we believe that reporting all
institute-wide CLABSI captures these cases appropriately. (Submitted by:
Alliance of Dedicated Cancer Centers)
| (Program: PPS-Exempt
Cancer Hospital Quality Reporting Program ; MUC ID: E1717) |
- We thank the Measure Applications Partnership Coordinating Committee for
the opportunity to provide comments on their 2014-2015 Preliminary
Recommendations for measures under consideration. CDI is the most common
bacterial cause of healthcare-associated diarrhea in patients receiving
chemotherapy for cancer with double the rate of hospital-onset CDI among
cancer patients compared to all US patients.1 Additionally, chemotherapy
itself has been identified as a risk factor for developing CDI in cancer
patients.2,3 It is for these reasons we feel measure E1717 has the potential
to improve patient outcomes through addressing the unmet burden of Clostridium
difficile infections (CDI) in patients with cancer. 1. Kamboj M, Son C, Cantu
S, et al. Hospital-onset Clostridium difficile infection rates in persons with
cancer or hematopoietic stem cell transplant: a C3IC network report. Infect
Control Hosp Epidemiol 2012;33:1162-5. 2. Chopra T, Alangaden GJ, Chandrasekar
P. Clostridium difficile infection in cancer patients and hematopoietic stem
cell transplant recipients. Expert review of anti-infective therapy
2010;8:1113-9. 3. Khan A, Raza S, Batul SA, et al. The evolution of
Clostridium difficile infection in cancer patients: epidemiology,
pathophysiology, and guidelines for prevention and management. Recent patents
on anti-infective drug discovery 2012;7:157-70.(Submitted by: Merck, Sharp and
Dohme, Inc.)
- Position: Do not adopt this measure. Relevance: CDI infections can be
life-threatening, particularly in immunocompromised cancer patients. Thus,
the ADCCís patients are at high risk for CDI, given the underlying factors
associated with the diagnosis and treatment of cancer. Common risk factors
for developing an active infection include advanced age, multiple
hospitalizations, prior antibiotic use, chemotherapy, broad spectrum
antimicrobial use for neutropenic fevers, graft-versus-host disease, and HSC
transplant.3-6 Thus, rigorous CDI control is essential to our patient safety
initiatives. Research suggests that 20-50% of patients admitted to an
inpatient facility are C. difficile carriers.7 Currently, routine C.
difficile screening in asymptomatic patients is not recommended by the Society
for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases
Society of America (IDSA). Therefore, many patients may become predisposed to
CDI due to previously undiagnosed infections at outside facilities. Thus, CDI
LabID events identified at the Cancer Centers may be unrelated to our care
delivery. Usability: The ADCC recognizes the importance of effective CDI
control in our hospitals. The Cancer Centers have adopted rigorous infection
control protocols to minimize CDI and to closely track active infections. A
significant limitation of this measure is that it does not take into account
the type of test used to diagnose CDI. The sensitivity and specificity of
existing CDI laboratory tests vary significantly across centers. For example,
real-time polymerase chain reaction (PCR) is a highly sensitive test, and its
usage is, therefore, associated with increased CDI rates. The use of
different laboratory tests (with varying levels of sensitivity and
specificity) to diagnose CDI across hospitals contributes to under-diagnosis
and/or false positive results and inaccurate comparisons of infection rates.
Hence, the lack of standardization in testing makes this an inappropriate
comparative measure. Until the measure has been revised to address this
issue, it should not be adopted for the PCHQR. Moreover, the ADCC favors
adoption of measures that focus on improved infection control practices,
rigorous antibiotic stewardship programs, and decreased incidence of HAI,
rather than surveillance measures such as this one. No other measures in the
PCHQR program address this aspect of patient care. Feasibility: As written,
this measure requires manual tracking of LabID events. However, several
centers currently track CDI as part of state surveillance or internal
infection control programs. Therefore, minimal additional burden is
anticipated with continued reporting of the measure. (Submitted by: Alliance
of Dedicated Cancer Centers )
- [Pre-workgroup meeting comment] Position: The ADCC believes that
using SIR of hospital-onset CDI laboratory identified events among all
inpatients in the facility is not an appropriate quality measure for the PCHQR
program. We do not support the inclusion of this measure in the PCHQR program.
Although the ADCC centers support C. Difficile infection surveillance
reporting, it must be recognized that the ADCC centers have a patient
population that is uniquely at risk for C. diff infections given the
underlying factors associated with the diagnosis and treatment of cancer.
Some of the common risk factors for developing an active infection include
multiple hospitalizations, prior antibiotics, advanced age, chemotherapy, and
hematopoietic stem cell transplant. Studies suggest that between 20-50% of
patients admitted to an inpatient facility are carriers of C. Difficile.
Currently, routine screening for C. Difficile in asymptomatic patients is not
recommended by the SHEA/IDSA (the Society for Healthcare Epidemiology of
America and the Infectious Diseases Society of America). Thus, many patients
have acquired the predisposition to develop an active C. Diff infection at
outside facility. In addition, the sensitivity and specificity of existing
laboratory tests varies significantly and under-diagnosis and/or false
positive results may lead to erroneous reporting. The ADCC recommends the
development of measures that focus on improved infection control practices to
decrease the incidence of hospital-acquired infections as well as the
implementation of rigorous antibiotic stewardship programs. Would addition of
the measure add value to the program measure set? Rate comparisons between
centers do not take into account the type of test used to diagnose C. Diff.
PCR is a highly sensitive test, and its usage is, therefore, associated with
increased rates of C. Diff. The use of PCR to diagnose patients provides an
inaccurate comparison of infection rates when juxtaposition to other
facilities using different (less sensitive) methodologies. The lack of
standardization in testing does not make this an appropriate comparative
measure. What is the measureís potential to improve patient outcomes? Cancer
patients are at high risk for CDI based on their unique medical history;
antibiotic use, chemotherapy, and frequent hospitalizations. Literature shows
hospital-acquired CDI rates in a large group of cancer patients to be well
above the reported rate for all US patients1,2,3,4. Epidemiologic
investigations have been conducted, and are often not able to show correlation
between nosocomial cases. This challenges the clear interpretation of CDI as a
reflection of poor infection control. Oncology patients frequently have health
care exposures prior to presenting at a comprehensive cancer facility.
Chemotherapy, broad spectrum antimicrobial use for neutropenic fevers, and
graft vs. host disease are associated with increased rates of CDI especially
in the early post-transplant period3. This may represent the expression of
diseases in a patient colonized elsewhere, and not ongoing transmission in the
hospital. Would use of the measure create undue data collection or reporting
burden? Consistent screening and the use of similar diagnostic tests across
centers is a challenge and may create additional costs and burden for centers.
Is there a better measure available or does a measure already in the program
set address a particular program objective? No. References: 1. Alonso CD,
Dufresne SF, Hanna DB, LabbÈ AC, Treadway SB, Neofytos D, BÈlanger S, Huff CA,
LaverdiËre M, Marr KA. Clostridium difficile infection after adult autologous
stem cell transplantation: a multicenter study of epidemiology and risk
factors. Biol Blood Marrow Transplant. 2013 Oct;19(10):1502-8.
doi:10.1016/j.bbmt.2013.07.022. Epub 2013 Aug 1. PubMed PMID: 23916741; PubMed
Central PMCID: PMC3806308. 2. Alonso CD, Marr KA. Clostridium difficile
infection among hematopoietic stem cell transplant recipients: beyond colitis.
Curr Opin Infect Dis. 2013 Aug;26(4):326-31. doi:
10.1097/QCO.0b013e3283630c4c. Review. PubMed PMID:23806895; PubMed Central
PMCID: PMC4222064. 3. Alonso CD, Treadway SB, Hanna DB, Huff CA, Neofytos D,
Carroll KC, Marr KA. Epidemiology and outcomes of Clostridium difficile
infections in hematopoietic stem cell transplant recipients. Clin Infect Dis.
2012 Apr;54(8):1053-63. doi:10.1093/cid/cir1035. Epub 2012 Mar 12. PubMed
PMID: 22412059; PubMed Central PMCID: PMC3309884. 4. Binion DG. Strategies for
management of Clostridium difficile infection in immunosuppressed patients.
Gastroenterol Hepatol (N Y). 2011 Nov;7(11):750-2.PubMed PMID: 22298971;
PubMed Central PMCID: PMC3264928. (Submitted by: Alliance of Dedicated Cancer
Centers)
| (Program: Hospital Outpatient Quality
Reporting Program; MUC ID: E1822) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
| (Program:
Hospital Value-Based Purchasing Program; MUC ID: E1893) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- [Pre-workgroup meeting comment] Agree with the addition of
following proposed text -The measure estimates a hospital-level
risk-standardized mortality rate (RSMR), defined as death from any cause
within 30 days after the index admission date, for patients 40 and older
discharged from the hospital with either a principal diagnosis of COPD or a
principal diagnosis of respiratory failure with a secondary diagnosis of acute
exacerbation of COPD. Along with other best practices currently identified,
the use of NIV in specific patient populations has been found to improve the
ability to obtain more favorable measures. CMS will annually report the
measure for patients who are 65 years or older, enrolled in fee-for- service
(FFS) Medicare, and hospitalized in non- federal hospitals. support:COPD is
the third leading cause of death in America, claiming over lives of 133,000
lives in 2010. Close to 24 million U.S. adults have evidence of impaired lung
function, indicating an under diagnosis of COPD. Patients with COPD and
hypercapnic respiratory failure have a worse prognosis and experience a faster
deterioration in their pulmonary function. These patients progress to have
worsening symptoms which require increasing inpatient hospitalizations. Recent
studies have shown that the use of NIV in these patients have reduced the rate
of readmissions as well as the associated mortality. In the Galli study,
Patients in the NPPV post discharge group demonstrated superior event-free
survival compared to the no-NPPV post discharge group (y2 Z 23.8, p <
0.0001). The NPPV post discharge group had a statistically significant
reduction in hospital readmissions (40% versus 75%, p < 0.0001) through 180
days from the index admission. (Galli et al, Respiratory Medicine (2014)
march, 1e7) (Submitted by: ResMed)
- [Pre-workgroup meeting comment] Complications, readmissions and
mortality after medical conditions or patient discharge may be reducible with
application of currently available patient monitoring technologies in the
acute care and home care setting. These patient monitoring technologies may
permit ìearly warningî of complications and permit intervention before
complications worsen to increase inpatient length of stay, cause unplanned
readmission, or cause death.(Submitted by: AdvaMed)
| (Program:
Hospital Outpatient Quality Reporting Program; MUC ID: E1898)
|
- AGS notes that this measure is addressed only to the hospitalís outpatient
environment. As a quality measure, health literacy should be screened by
providers on all inpatient admissions. This affects patientsí adherence with
both their inpatient care plan and subsequent outpatient care plan.
(Submitted by: American Geriatrics Society)
- The process is too burdensome to oversee. It is better to include a
question on if communication of practice is able to be understood in plain
terms on a patient satisfaction survey that is previously graded to a sixth
grade reading level, like all standard surveys.(Submitted by: Johns Hopkins
Hospital)
- We understand the need to address disparities among populations receiving
health care and we support the implementation of an outpatient quality measure
to evaluate the health literacy component of patient-centered communication as
a way to do so. However, do not support the implementation of this measure. We
strongly support the development and continued testing of the
"Outpatient/Ambulatory Surgery Patient Experience of Care Survey (O/ASPECS)"
with the goal of the survey tool becoming a CAHPS tool that can be used as a
measure under the Outpatient Quality Reporting Program. We believe that it
would be confusing and burdensome for patients to receive both the O/ASPECS
tool and the C-CAT survey tool. Many of the survey topics are highly
correlated and some questions even have similar if not exact wording. Patients
may be less likely to complete the second survey, possibly thinking that they
had already done so. Instead of two separate surveys, we would encourage CMS
to adapt the O/ASPECS survey tool that is currently being tested to include
additional health literacy focused questions, possibly from the C-CAT survey
tool. This would remove the burden from patients having to respond to multiple
surveys and remove the burden from outpatient providers of having to
administer two different surveys. (Submitted by: Press Ganey
Associates)
- Very concerned about the excessive burden of implementing this
measure.(Submitted by: Park Nicollet Methodist Hospital)
| (Program: End-Stage Renal Disease Quality
Incentive Program ; MUC ID: E1919) |
- ASN does not support Measure E1919 and therefore does not support Measure
X3716. ASN believes that Measure E1919 is not adequately validated in
dialysis facilities, which in general are far smaller than the institutions in
which the majority of testing occurred. While we agree that many of the
preferred practices listed are useful for running medium and large-sized
organizations, they are not appropriate for a facility level quality metric,
where a small business model on the very local level is often followed.
Critically, in the limited period of time provided for reviewing these
proposed measures, we were unable to locate details of documentation of
testing of this measure in dialysis facilities, although as best can be
discerned from the measure specification, it was field tested at only 7
dialysis facilities in Texas only. Accordingly, we concur with the PAC/LTC
Workgroup that voted 56% to 44% against support. As stated in our prior
comments, ASN notes that this type of measure is designed to improve patient
experience; therefore, there is considerable overlap between the ëPreferred
Practicesí in NQF 1919 and the items surveyed in the ICH CAHPS. Additionally,
many of the ëPreferred Practicesí do not readily apply to the facility level,
with these best implemented by organizations with fairly large staffs. For
example, ëPreferred Practice 4í states: ìEstablish an internal mechanism for
developing strategies that involve using a committee of current diverse staff
for recruitment, retention, and promotion of staff that reflect the community
at all levels of the organization (including upper management).î This, as
written, clearly does not apply to a facility where there may be between 10
and 20 employees. Additional several of these elements are duplicative with
the ESRD Conditions for Coverage (see tags V451, V451, V452, V453), while
others (for example Preferred Practice 30) refer to following existing local,
state and federal laws and regulations, a statement that should not require a
QIP metric. Preferred Practice 32, on community outreach, states in the
specifications that: ìOrganizations should collaborate with community
organizations, in particular for health education programs, where they can
help to raise awareness about local healthcare services.î This implies a role
for prevention in the community, which, although important, is currently not a
goal of dialysis facilities and will not impact current patients. While NQF
1919 is well-intentioned, most of the 12 preferred practices are beyond the
scope of individual dialysis facilities, which should, per their mission, be
focused on delivering dialysis care. In sum, 1) this measure does not readily
apply to many individual dialysis facilities, 2) elements which are applicable
are generally already addressed within existing laws and the Conditions for
Coverage, 3) elements within this measure that are applicable will be captured
in ICH CAHPS which assesses patient impressions of whether competent care is
occurring, and 4) this measure could substantially increase documentation
demands and facility burdens with no evidence of a beneficial effect on
dialysis patient outcomes. (Submitted by: American Society of Nephrology
(ASN))
- We are not supportive or the RAND cultural measure as our review of the
supporting documentation does not show sufficient testing in ESRD facilities.
More testing needs to be done to determine feasibility in an ESRD
setting.(Submitted by: DaVita Healthcare Partners)
- KCP acknowledges that cultural competency is an important health care
priority and that the cultural competency MUCs would serve to expand the ESRD
measure set to include nonclinical aspects of care such as patient engagement.
However, KCP believes that as these measures have neither been adequately
tested in the dialysis facility setting nor demonstrated as having any impact
on patient care or outcomes, they are not appropriate for use in the QIP,
which should be limited to care delivery in the dialysis facility setting. As
with the medications reconciliation MUCs, the PAC/LTC Workgroup voted 56% to
44% against support (E1919) and conditional support pending NQF endorsement
(X3716). KCP concurs and opposes both E1919 and X3716, and urges the MAP
Coordinating Committee to do likewise. KCP notes that while E1919 is
NQF-endorsed and is in use for internal and external QI purposes, it has not
been used for public reporting or payment. Moreover, while E1919 was
specified for use in and has been tested in dialysis facilities (among other
settings), testing was limited to seven dialysis facilities within a single
organization in Texas. Given the uniqueness of the setting and the complexity
of the patients receiving care therein, KCP does not believe that this level
of testing is sufficient to deem the measure appropriate for use in dialysis
facilities. KCP also stresses that, given the intrinsic burden associated
with health care surveys, whatever cultural competency measure is ultimately
adopted for use in the QIP should be empirically linked to at least some
improvement in care and/or outcomes stemming from the assessment. This has
not yet been demonstrated for this measure. We additionally note that there
is some overlap with the ICH-CAHPS domains. As research is currently abundant
in this area, we urge the MAP Coordinating Committee to wait for the
development of a more appropriate cultural competency tool, with no redundancy
with existing surveys and a demonstrative efficacy in the dialysis setting.
KCP reiterates that the issue of burden is complex and must be approached
with caution. Each survey required places a heavier load on physicians,
staff, and patients. We stress that it is critically important before
adopting the cultural competency measures that additional testing be performed
and that use of the measures in the dialysis facility setting be better
understood. We believe that as currently specified, E1919 and its reporting
measure X3716 would be burdensome and have not been demonstrated to yield
accurate data or to improve care, outcomes, or patient experience in the
dialysis facility setting. Accordingly, the measures should not be
supported/conditionally supported (respectively) by the MAP.(Submitted by:
Kidney Care Partners (KCP))
- 2. NKF believes that the dialysis care team should be properly trained on
how to communicate, prescribe and deliver healthcare in a manner that respects
individualsí beliefs, attitudes, and behaviors and that overcomes language
barriers. However, because the measures of cultural competency are based on
another survey tool that is in part redundant with the in-center hemodialysis
CAHPs survey, NKF opposes the cultural competency measures as designed:
ï E1919 Cultural Competency Implementation Measure ï X3716 Cultural
Competency Reporting Measure The tool used to evaluate cultural competency has
some overlap with the in-center hemodialysis CAHPs survey for which twice a
year administration is already a requirement in the ESRD QIP and will be used
to evaluate patient satisfaction with their care in 2018. Requiring
completion of an additional survey places a burden on patients and healthcare
practitioners. Until such a time that one survey tool can be designed that
incorporates both relevant patient satisfaction questions and cultural
competency questions we believe that a separate measure of cultural competency
would only place an undue burden on patients and counteract much of the
benefit.(Submitted by: National Kidney Foundation)
- [Pre-workgroup meeting comment] ASN does not support Measure E1919
and therefore does not support Measure X3716. ASN believes that Measure E1919
is not adequately validated in dialysis facilities, which in general are far
smaller than the institutions in which the majority of testing occurred. While
we agree that many of the preferred practices listed are useful for running
medium and large-sized organizations, they are not appropriate for a facility
level quality metric, where a small business model on the very local level is
often followed. Critically, in the limited period of time provided for
reviewing these proposed measures, we were unable to locate details of
documentation of testing of this measure in dialysis facilities, although as
best can be discerned from the measure specification, it was field tested at 7
dialysis facilities in Texas only. This type of measure is designed to improve
patient experience; therefore, there is considerable overlap between the
ëPreferred Practicesí in NQF 1919 and the items surveyed in the ICH CAHPS.
Additionally, many of the ëPreferred Practicesí do not readily apply to the
facility level, with these best implemented by organizations with fairly large
staffs. For example, ëPreferred Practice 4í states: ìEstablish an internal
mechanism for developing strategies that involve using a committee of current
diverse staff for recruitment, retention, and promotion of staff that reflect
the community at all levels of the organization (including upper management).î
This, as written, clearly does not apply to a facility where there may be 10
to 20 employees. Additional several of these elements are duplicative with the
ESRD Conditions for Coverage (see tags V451, V451, V452, V453), while others
(for example Preferred Practice 30) refer to following existing local, state
and federal laws and regulations, a statement that should not require a QIP
metric. Preferred Practice 32, on community outreach, states in the
specifications that: ìOrganizations should collaborate with community
organizations, in particular for health education programs, where they can
help to raise awareness about local healthcare services.î While NQF 1919 is
well-intentioned, most of the 12 preferred practices are beyond the scope of
individual dialysis facilities, which should, per their mission, be focused on
delivering dialysis care. In sum, 1) this measure does not readily apply to
many individual dialysis facilities, 2) elements which are applicable are
generally already addressed within existing laws and the Conditions for
Coverage, 3) elements within this measure that are applicable will be captured
in ICH CAHPS which assesses patient impressions of whether competent care is
occurring, and 4) this measure could substantially increase documentation
demands and facility burdens with no evidence of a beneficial effect on
dialysis patient outcomes.(Submitted by: American Society of
Nephrology)
| (Program: Medicare Shared Savings Program; MUC ID:
E2079) |
- HIVMA strongly supports monitoring the outcomes of patients with HIV
infection who are enrolled in the Medicare Shared Savings Program. We support
the MAPís recommendation to develop rolled-up or composite measures for
specific conditions, including HIV/AIDS, with the involvement of HIV experts
including HIVMA members. (Submitted by: HIV Medicine Association)
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as they fill
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program: Medicare Shared Savings Program; MUC ID:
E2082) |
- HIVMA strongly supports monitoring the outcomes of patients with HIV
infection who are enrolled in the Medicare Shared Savings Program. We support
the MAPís recommendation to develop rolled-up or composite measures for
specific conditions, including HIV/AIDS, with the involvement of HIV experts
including HIVMA members.(Submitted by: HIV Medicine Association)
- The clinician workgroup reviewed the measure, ìHIV viral load suppressionî
for inclusion in the MSSP, but determined to not include this outcome measure
and instead include a composite measure. Achievement of HIV viral load
suppression is the result of high quality care, adequate patient management,
and appropriate pharmacologic treatment. This one outcome measure
demonstrates the quality of care being rendered without use of a
multicomponent composite. This recommendation runs counter to the NQF goals
of parsimony and preference for ìhigh-valueî outcome measures. We recommend
reconsideration of the HIV Viral Load Suppression measure as a single outcome
measure for HIV treatment for the MSSP measure set.(Submitted by:
GlaxoSmithKline)
- [Pre-workgroup meeting comment] We are in support of use of this
measure as it fill important gaps in measurement. We would appreciate the
inclusion of more infectious diseases related measures into federal reporting
programs to help improve the quality of care of patients with infectious
diseases and to ensure that infectious diseases specialists have more relevant
measures to choose from when attempting to satisfy reporting requirements
across federal programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program: Medicare Shared Savings Program;
MUC ID: E2083) |
- HIVMA strongly supports monitoring the outcomes of patients with HIV
infection who are enrolled in the Medicare Shared Savings Program. We support
the MAPís recommendation to develop rolled-up or composite measures for
specific conditions, including HIV/AIDS, with the involvement of HIV experts
including HIVMA members.(Submitted by: HIV Medicine Association)
- [Pre-workgroup meeting comment] We are in support of use of this
measure as it fills important gaps in measurement. We would appreciate the
inclusion of more infectious diseases related measures into federal reporting
programs to help improve the quality of care of patients with infectious
diseases and to ensure that infectious diseases specialists have more relevant
measures to choose from when attempting to satisfy reporting requirements
across federal programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program: Medicare Shared Savings Program;
MUC ID: E2111) |
- The Pharmacy Quality Alliance (PQA) appreciates the opportunity to provide
input on the proposed set of measures compiled by CMS and under consideration
for use by the Medicare program. Our comments are in support of MUC ID E2111,
Antipsychotic Use in Persons with Dementia, which is an NQF-endorsed
medication safety measure proposed for use in the Medicare Shared Savings
program. Addition of this measure will add value to the measure set because
of its focus on individuals 65 years and older with dementia who are receiving
antipsychotic medications without evidence of a psychiatric disorder or
related condition, and for which there is evidence of harm from such use.
Evidence shows that antipsychotic medications increase the risk of death and
cerebrovascular events in people with dementia. Use of this measure should
not create undue data collection or reporting burden because the data needed
to calculate the measure exists as diagnostic codes or prescribing data in the
medical record (appropriate codes and diagnoses for the measure are defined
within the measure specifications). We believe this is the best measure
available to address inappropriate use of antipsychotic medications in
patients with dementia because it targets a population for which there is
increasing concern of harm from overuse of antipsychotic drugs, and uses
readily available data. (Submitted by: Pharmacy Quality Alliance
(PQA))
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. SEIU supports the MAP position of supporting this
measure for use in the Medicare Shared Savings Program. The inappropriate use
of antipsychotic drugs is an important issue that must be addressed, not just
for persons with dementia, but for all beneficiaries in post-acute and long
term care settings. (Submitted by: SEIU)
| (Program: Medicare Shared Savings Program; MUC ID: E2152)
|
- [Pre-workgroup meeting comment] I strongly support use of this
measure. However, it's only a first step. This metric will not reflect the
quality of the intervention. Mere brief advice would satisfy the metric but
not elicit the behavior change and the cost savings obtained in prior
RCTs.(Submitted by: Wisconsin Initiative to Promote Healthy
Lifestyles)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: E2152) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- This eMeasure has been fully developed, specified and tested and received
NQF endorsement in 2013. It's unclear why the MAP felt that continued
development is necessary. (Submitted by: AMA PCPI)
- MAP indicated that alcohol screening and brief intervention is evidence
based andencouraged further development of this eMeasure. This eMeasure has
been fully developed, specified and tested and received NQF endorsement in
2013. It's unclear why the MAP felt that continued development was necessary.
(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] 20-25% of patients presenting to
the health care system have medical conditions that are caused or worsened by
unhealthy alcohol use. Yet, most remain unscreened and diagnosed. It is a
neglected epidemic. Any incentive to increase detection, and providing medical
advice or a referral will enable physicians to offer better patient care,
including more accurate diagnosis, better management, safer prescribing
practices, and this can be easily done by incorporating it into the EHR, with
little cost, effort, and expense. (Submitted by: University of
Texas)
- [Pre-workgroup meeting comment] I strongly support use of this
measure. However, it's only a first step. This metric will not reflect the
quality of the intervention. Mere brief advice would satisfy the metric but
not elicit the behavior change and the cost savings obtained in prior
RCTs.(Submitted by: Wisconsin Initiative to Promote Healthy
Lifestyles)
- [Pre-workgroup meeting comment] I strongly endorse this measure to
address prevention of unhealthy alcohol use. It aligns with with the USPSTF
grade B recommendation to offer alcohol screening and brief intervention in
primary care; and with the Partnership for Prevention Priorities Among
Effective Preventive Services. We know this prevention service is highly
underutilized but also that it can be efficiently implemented into primary
care settings.(Submitted by: Peer Assistance Services, Inc.)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: E2152)
|
- AGS agrees that this should be included as unhealthy alcohol use is an
important public health issue. In addition, unhealthy alcohol use may be
overlooked as a contributor to functional and cognitive impairments in older
persons.(Submitted by: American Geriatrics Society)
- This eMeasure has been fully developed, specified and tested and received
NQF endorsement in 2013. It's unclear why the MAP felt that continued
development is necessary. We would urge the MAP to reconsider its preliminary
recommendation and fully support its inclusion in the PQRS and EHR incentive
programs.(Submitted by: AMA PCPI)
- ASN does not support this measure and agrees with NQF regarding the
measuresí need to be fully developed before it is reconsidered. (Submitted by:
American Society of Nephrology (ASN))
- [Pre-workgroup meeting comment] Having worked on the implementation
of ASBI for over 25 years, I strongly endorse E2152 for all the reasons cited
in the rationale--plus some. Several studies have determined that this service
is underutilized by PCPs. Thus, many practitioners regularly prescribe
pharmaceuticals without attention to contraindications among patients who
drink alcohol excessively, and they fail to consider alcohol use in diagnosing
and treating many common medical conditions. Moreover, excessive alcohol use
has been shown to cause or aggravate many common medical conditions. However,
as an author of the WHO manual on the AUDIT screening instrument and a recent
CDC adaptation of the AUDIT to the US standard drink size and NIAAA
consumption guidelines, I must point out one weakness in the specifications of
the current measure. On p. 145-6 the AUDIT-C is listed as a recommended
screening instrument despite the fact that it is flawed and produces many
unacceptable false positives (especially among women). It would be far better
now to use the AUDIT 1-3 (US) as recently published by the CDC. See
http://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf. I
hope you will cite and recommend this publication and its forms of the AUDIT
produced specifically for the US market. John C. Higgins-Biddle, Ph.D.
johnhb7@comcast.net(Submitted by: University of Connecticut School of
Medicine, Retired)
- [Pre-workgroup meeting comment] Unhealthy alcohol use affects one
out of six adults. Without screening, the problems are not detected until the
they are later, more advanced stages. Physicians should be compared based upon
whether they neglect or diagnose unhealthy alcohol use and other risky
behaviors.(Submitted by: University of Texas)
- [Pre-workgroup meeting comment] I strongly support use of this
measure. However, it's only a first step. This metric will not reflect the
quality of the intervention. Mere brief advice would satisfy the metric but
not elicit the behavior change and the cost savings obtained in prior
RCTs.(Submitted by: Wisconsin Initiative to Promote Healthy
Lifestyles)
- [Pre-workgroup meeting comment] I strongly endorse this measure to
address prevention of unhealthy alcohol use. It aligns with with the USPSTF
grade B recommendation to offer alcohol screening and brief intervention in
primary care; and with the Partnership for Prevention Priorities Among
Effective Preventive Services. We know this prevention service is highly
underutilized but also that it can be efficiently implemented into primary
care settings.(Submitted by: Peer Assistance Services, Inc.)
- [Pre-workgroup meeting comment] ASN does not support this measure;
ASN believes that this may be an appropriate measure as a primary care metrics
but is not suitable for dialysis facilities.(Submitted by: American Society of
Nephrology (ASN))
- [Pre-workgroup meeting comment] I strongly support. NQF and CDC
also endorse. (Submitted by: School of Public Health University of Illinois at
Chicago )
| (Program: Medicare Shared
Savings Program; MUC ID: E2158) |
- The AMA does not support this measure. ACOís shared savings payment is
alrealready based on their spending per beneficiary and the measure is
redundant. NQFís endorsement criteria require that a measure must be shown to
be reliable and valid, but this measure did not receive the clear support from
the Steering Committee about these criteria. In fact, the Steering Committee
members voiced numerous concerns about the reliability and validity for this
measure; AMA echoes these concerns. Moreover, the AMA is concerned that the
90-day look-back period to capture a patientís co-morbidities in order to
determine the hierarchical condition categories (HCC) score is insufficient.
There is precedent for utilizing a longer look-back period: the HCC risk
adjustment model used for the current mortality and readmission measures
utilizes a one year look-back period. In addition, although the complex
methodology of this measure helps improve the accuracy of the measurement, it
also makes it more difficult for providers to monitor and improve upon their
own performance. It remains unclear how this measure can be used to determine
good performance, poor performance, or how it could be used by providers to
help improve their own performance. Finally, because the proposed measure
does not demonstrate the linkage of expenditures as a result of quality
achieved, the proposed measure will not provide actionable information that a
hospital and physician could use to identify how to make improvements.
(Submitted by: American Medical Association)
- Premier along with CMS and the public in general is concerned that the
current level of healthcare spending is unsustainable. It is with this in
mind that CMS created the shared savings program, the purpose of which was to
incentivize organizations to provide efficient care. The publically reported
quality measures for this program are meant to ensure that quality does not
suffer as stewardship of resources increases. This measure fails to do this.
It is not a balancing measure of quality, but rather a redundant measure of
the cost goal of the program, the primary measure of which is the shared
savings component. As important as this measure is, it does not conform to
the philosophy which established the reporting of quality measures in the
first place. (Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] We would like to reiterate our
sentiments expressed in our comment letter to the 2015 Physician Fee Schedule
Proposed Rule, which stated our concerns over the cost attribution methodology
for the Payment-Standardized Medicare Spending Per Beneficiary (MSPB) measure.
In particular, this measure holds physicians accountable for the totality of
costs associated with the care of a patient, which incorrectly assumes that
physicians have control over the care plan and treatment decisions of other
physicians who also treated the patient over the reporting year.(Submitted by:
The Infectious Diseases Society of America)
| (Program: Hospital-Acquired Condition (HAC) Reduction
Program ; MUC ID: S0138) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- The Consumer-Purchaser Alliance is concerned about the recommended
condition that these measures be used in the Hospital Value-Based Purchasing
Program (HVBP)only following public reporting. We believe this condition
would only be appropriate as statutorily mandated. Moreover, we fully support
the swift and simultaneous implementation of these measures within the HVBP
program and across all other programs in which they are already in use. We
believe immediate implementation of the most recent version of the measure
will support continued alignment of measures across federal programs and
ensure that the most scientifically rigorous and up-to-date versions of
NQF-endorsed measures are implemented in a timely fashion. Additionally, we
would like to draw attention to results from the FY 2015 HVBP program, which
indicate that over 50% of eligible hospitals received payment incentives
through this program based on demonstrated performance. This figure
represents a rise in hospitals benefiting from the program from the year
prior, and we caution MAP against recommending an approach to measure updates
that might result in slowed progress or steps backwards from the success
achieved to date in improving health care quality.(Submitted by:
Consumer-Purchaser Alliance)
- Hospitals already monitor this.(Submitted by: American Academy of
Pediatrics)
- [Pre-workgroup meeting comment] The following is from a letter from
the president of the American Spinal Injury Association (ASIA), a professional
organization dedicated to the care of patients with Spinal Cord Injury (SCI).
This letter was approved by ASIAís board of directors prior to its release. I
have emailed a scanned copy of this letter, with letterhead and signature, to
Robert Saunders, senior director of the NQF: Drs. Frieden, Pollock, Gould,
and Pines: As care providers of patients with Spinal Cord Injuries (SCI), we
are seeing an alarming increase in the number of patients whose bladders are
managed in an unsafe manner following the transition last October toward ìPay
for Performanceî status of the National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure.
Hospitals' emphasis on removal of indwelling catheters is not surprising,
given the financial penalties involved and the public reporting of CAUTI rates
as an indicator of "quality healthcare." Unfortunately, most non-specialty
hospital settings are not adequately experienced in implementing an
intermittent catheterization (IC) program. Many physicians and nurses, in
fact, are not even aware of the need to perform IC in SCI patients. The
Consortium for Spinal Cord Medicine's Clinical Practice Guidelines for Bladder
Management for Adults with Spinal Cord Injury, one of the most definitive and
widely-accepted treatises on the subject, clearly indicate that indwelling
catheterization is preferable to poorly-implemented IC. While many of us
prefer suprapubic catheters to Foley catheters in the long term, this option
is simply not available in the first several weeks following SCI.
Additionally, the CAUTI measure focuses exclusively on UTI risk as the sole
consideration in selecting the method of bladder management in SCI. We believe
that indwelling catheterization remains a valuable option in a substantial
portion of SCI patients for a variety of reasons. Once again, these reasons
are outlined in the Clinical Practice Guidelines, which were assembled through
a rigorous review of the literature and of expert consensus by a team of
Neuro-Urologists, Certified Rehabilitation Nurses, and Physiatrists who
sub-specialize in SCI. Facilities which judiciously use indwelling catheters
are by no means providing substandard care. The public reporting of CAUTIs as
an indicator of "quality healthcare" in SCI patients adds insult to injury. It
risks leading patients and their families to facilities poorly equipped to
handle this catastrophic injury. Facilities without the insight to use
indwelling catheters judiciously will appear to be providing better care than
SCI specialty centers. Inadequately-implemented (or nonexistent) IC puts SCI
patients at risk for upper urinary tract deterioration, autonomic dysreflexia
(with resulting hypertensive emergency), and UTI related to urinary retention.
By indiscriminately removing Foley catheters, non-specialty hospitals can see
their CAUTI rates decline, while these life-threatening adverse consequences
are going unmeasured and unrecognized. One solution suggested by the CDC has
been that SCI physicians educate the medical community as a whole about how to
properly implement IC and how to identify which patients are appropriate for
continued foley use. Unfortunately, these are complicated decisions which are
usually made SCI sub-specialists working in tertiary care centers with
specialty-trained nurses. Most acute care nursing units see very few SCI
patients in a year. The operational feasibility of such a solution seems very
small, especially given the financial disincentives in place. The financial
penalty and public reporting of the CAUTI measure are driving practices which
deviate from acceptable medical care for patients with SCI. Accordingly, we
are requesting that CDC-NHSN add UTIs in SCI patients to the list of UTIs that
are excluded from a hospitalís CAUTI count, in a similar manner that UTIs
related to suprapubic catheters are excluded. Sincerely, Michael H. Haak, MD
ASIA President (Submitted by: American Spinal Injury
Association)
- [Pre-workgroup meeting comment] Patients with spinal cord injuries
(SCI) often require the use of indwelling catheters to manage their neurogenic
bladders. In an effort to comply with the publicly-reported CAUTI outcome
measure, some physicians who are treating SCI patients with indwelling
catheters are removing these catheters in direct conflict with the only
published clinical practice guideline on the subject (Linsenmayer, T. (Ed.)
Bladder Management for Adults with Spinal Cord Injury: A clinical practice
guideline for health-care providers. (Washington, DC: Consortium of Spinal
Cord Medicine, 2006).). This action may compromise the short- and long-term
health of the patient with SCI in ways that are unknown to the treating
physician and perhaps even the patients themselves. On behalf of patients
with spinal cord injuries, I respectfully ask that patients with spinal cord
injuries be administratively excluded from this outcome measure. While the
CAUTI measure is clinically appropriate for the general population, the
guidelines for SCI population indicate that catheters are the preferred
bladder management solution for certain SCI patients. Unfortunately, these
guidelines are unfamiliar to many physicians who see only small numbers of
patients with SCI; in ignorance of the published CPG, many physicians are
removing catheters inappropriately to comply with the CAUTI measure. The
authors of the CPG have been trying to raise awareness of the guidelines
existence for many years among the general physician population. This has been
to small avail; the SCI population is simply too small for every physician to
read and recall guidelines specific to this group. The CAUTI measure, on the
other hand, is driving clinical decision-making because it is
publicly-reported and tied (albeit indirectly) to reputation and ultimately
reimbursement. Specialists in the field of spinal cord medicine have come to
the consensus that indwelling catheters are appropriate for a portion of the
SCI population; we respectfully request that patients with spinal cord
injuries be administratively excluded from the CAUTI reporting guidelines as
the removal of indwelling catheters in this population follows a treatment
algorithm that differs from the general public and which is unknown to many
physicians who only treat the occasional patient with spinal cord injury.
(Submitted by: Quality of Life Advisors, Inc.)
- [Pre-workgroup meeting comment] I am comment on behalf of myself
and not representing Select Medical or Kessler Institute or PVA. I am the
Director of Urology at Kessler Institute for Rehabilitation and have been
working with SCI patients for the past 25 years. I am one of 2 urologists in
the country who is double boarded in Urology, Physical Medicine and
Rehabilitation as well as Spinal Cord Injury Medicine. I am the chairman of
the PVA SCI Consortium Guidelines on Bladder Management in Those With SCI. I
am also one of the committee members and authors of the recently published
International Data Set on UTIís in Those with SCI. While I think the
guidelines have a lot of merit in not leaving in a catheter in able bodied
individuals in an acute care hospital setting, I am very concerned with the
current CAUTI guidelines as they apply to those with indwelling catheters and
have an SCI. The financial penalty and public reporting of the CAUTI measure
encouraging the practice of removing a catheter in certain SCI individuals
which deviate from acceptable medical care for patients with SCI. Part of the
problem is that the definition of a UTI is very different in individuals with
SCI and neurogenic bladders compared to those who do not have a SCI.
Increased bacteria in the urine is considered to be the definition of a UTI in
non SCI, able bodied individuals. However, those with SCI WITH and WITHOUT an
indwelling catheter are routinely are colonized with bacteria in their
bladder. There is strong consensus that a person with a SCI should not be
considered to have an UTI just because of having bacteria in the bladder.
While there can be exceptions, 3 criteria need to be met to meet the
definition of a UTI in an individual with a SCI. These are; 1. bacteria in the
bladder (which almost all SCI individuals have), 2. increased WBCís in the
urine (that can occur from passing a catheter during intermittent
catheterization or an indwelling catheter) and very important, 3. the NEW
onset of symptoms. Our SCI bladder management consortium guidelines
(Linsenmeyer, T. (Ed.) Bladder Management for Adults with Spinal Cord Injury:
A clinical practice guideline for health-care providers. (Washington, DC:
Consortium of Spinal Cord Medicine, 2006).) specifically state that an
indwelling catheter should be considered in individuals who have poor hand
function and unable to catheterize themselves or do not have a willing
caregiver. This is because it is essential that the bladder is drained in a
timely manner. If a person is unable to catheterize themselves and the bladder
gets overdistended they can get a UTI or sepsis. In addition, if a person has
a SCI at T6 level or above (which includes those with poor hand function),
failure to drain the bladder can lead to a sudden severe potentially life
threatening rise in BP called autonomic dysreflexia. An indwelling catheter
is the safest way to keep this from happening. Also it is during the inpatient
setting that a person with a SCI and their family learn how to take care of
an indwelling catheter. If they are not taught how to manage an indwelling
catheter, the result is frequently to send a person home on intermittent
catheterization. The ìcaregiverî in most situations is a family member, so
that a wife or husband, mother or father has to suddenly take on the role of a
ìcaregiverî rather than a spouse, or a mother is now having to catheterize her
21 year old son around the clock. Intermittent catheterization requires
getting undressed so that a catheter can be passed down a persons urethra
every 4 to 6 hours and requires the trained person be available at all times
in case their bladder fills up quickly and the person with the SCI starts to
get autonomic dysreflexia. So now, as a result of having to perform
intermittent catheterization instead of having an indwelling catheter, both
the person with the SCI and person performing intermittent catheterization
need to be with each other at all times and causing both lose their
independence and have a significant decrease in their quality of life. This
is not the case with an indwelling catheter where there is a drainage bag
attached under the pants of the lower leg and can easily be reached and
drained by an untrained person by just twisting a small valve at the bottom of
the drainage bag. The other scenario is that a person with a long term SCI
and indwelling catheter is admitted to an acute care hospital for some medical
problem. The bladder becomes smaller with an indwelling catheter, and if it
were removed by a hospital staff that was not familiar with SCI in order to
decrease the risk of a financial penalty and public reporting of a CAUTI, the
SCI person would most certainly develop autonomic dysreflexia because of rapid
overdistention of their small bladder capacity. It should also be noted that
evaluation and management of acute autonomic dysreflexia is something that
most acute care hospital staff are not use to dealing with. In summary,
indwelling catheters for some SCI individuals is not only medically safer, but
allows a much better quality of life. The definitions of a UTI are also
different in those with an SCI. Under the definition of a UTI for able bodied
individual, almost all of our SCI patients who are colonized with bacteria,
with and without an indwelling catheter would be considered to have a UTI.
Those with an indwelling catheter would be classified as having a CAUTI.
Unfortunately, the financial penalty and public reporting of the CAUTI measure
are driving practices of removing catheters in those who cannot catheterize
themselves, which deviate from acceptable medical care for patients with SCI.
I therefore request that CDC-NHSN add UTIs in SCI patients to the list of
UTIs that are excluded from a hospitalís CAUTI count, in a similar manner that
UTIs related to suprapubic catheters are excluded. Respectfully submitted, Dr.
Todd Linsenmeyer, MD (Submitted by: Kessler Institute)
- [Pre-workgroup meeting comment] I have made a few minor editorial
changes from my comments recently submitted. Please use the following comment
instead. Thank you. T.L. I am commenting on behalf of myself and not
representing Select Medical or Kessler Institute or PVA. I am the Director of
Urology at Kessler Institute for Rehabilitation and have been working with SCI
patients for the past 25 years. I am one of 2 urologists in the country who is
double boarded in Urology, Physical Medicine and Rehabilitation as well as
Spinal Cord Injury Medicine. I am the chairman of the PVA SCI Consortium
Guidelines on Bladder Management in Those With SCI. I am also one of the
committee members and authors of the recently published International Data Set
on UTIís in Those with SCI. While I think the guidelines have a lot of merit
in not leaving in a catheter in able bodied individuals in an acute care
hospital setting, I am very concerned with the current CAUTI guidelines as
they apply to those with indwelling catheters and have an SCI. The financial
penalty and public reporting of the CAUTI measure are encouraging the practice
of removing catheters in certain SCI individuals, which deviate from accepted
medical care for patients with SCI. Part of the problem is that the
definition of a UTI is very different in individuals with SCI and neurogenic
bladders compared to those who do not have a SCI. Increased bacteria in the
urine is considered to be the definition of a UTI in non SCI, able bodied
individuals. However, those with SCI WITH and WITHOUT an indwelling catheter
are routinely are colonized with bacteria in their bladder. There is strong
consensus that a person with a SCI should not be considered to have an UTI
just because of having bacteria in the bladder. While there can be
exceptions, 3 criteria need to be met to meet the definition of a UTI in an
individual with a SCI. These are; 1. bacteria in the bladder (which almost all
SCI individuals have), 2. increased WBCís in the urine (that can occur from
passing a catheter during intermittent catheterization or an indwelling
catheter) and very important, 3. the NEW onset of symptoms. Our SCI bladder
management consortium guidelines (Linsenmeyer, T. (Ed.) Bladder Management
for Adults with Spinal Cord Injury: A clinical practice guideline for
health-care providers. (Washington, DC: Consortium of Spinal Cord Medicine,
2006) specifically state that an indwelling catheter should be considered in
individuals who have poor hand function and unable to catheterize themselves
or do not have a willing caregiver. This is because it is essential that the
bladder is drained in a timely manner. If a person is unable to catheterize
themselves and the bladder gets over distended they can get a UTI or sepsis.
In addition, if a person has a SCI at T6 level or above (which includes those
with poor hand function), failure to drain the bladder can lead to a sudden
severe potentially life threatening rise in BP called autonomic dysreflexia.
An indwelling catheter is the safest way to keep this from happening. Also it
is during the inpatient setting that a person with a SCI and their family
learns how to take care of an indwelling catheter. If they are not taught how
to manage an indwelling catheter, the result is frequently to send a person
home on intermittent catheterization. The ìcaregiverî in most situations is a
family member, so that a wife or husband, mother or father has to suddenly
take on the role of a ìcaregiverî rather than a spouse, or a mother now has to
catheterize her 21 year old son around the clock. Intermittent
catheterization requires getting undressed so that a catheter can be passed
down a personís urethra every 4 to 6 hours and requires the trained person be
available at all times in case their bladder fills up quickly and the person
with the SCI starts to get autonomic dysreflexia. So now, as a result of
having to perform intermittent catheterization instead of having an indwelling
catheter, both the person with the SCI and person performing intermittent
catheterization need to be with each other at all times and causing both lose
their independence and have a significant decrease in their quality of life.
This is not the case with an indwelling catheter where there is a drainage
bag attached under the pants of the lower part of the leg and can easily be
reached and drained even by an untrained person by just twisting a small
valve at the bottom of the drainage bag. Another scenario is that a person
with a long term SCI and indwelling catheter is admitted to an acute care
hospital for a non UTI medical problem. The bladder becomes smaller with an
indwelling catheter, and if it were removed by a hospital staff that was not
familiar with SCI, in order to decrease the risk of a financial penalty and
public reporting of a CAUTI, the SCI person would most certainly develop
autonomic dysreflexia due to rapid over distention of their small bladder
capacity. It should also be noted that evaluation and management of acute
autonomic dysreflexia is something that most acute care hospital staff are not
use to dealing with. In summary, indwelling catheters for some SCI
individuals are not only medically safer, but allow a much better quality of
life. Under the definition of a UTI for able bodied individual, almost all of
our SCI patients who are colonized with bacteria, with and without an
indwelling catheter would be considered to have a UTI. Those with an
indwelling catheter would be classified as having a CAUTI. Unfortunately, the
financial penalty and public reporting of the CAUTI measure are driving
practices of removing catheters in those with SCI who cannot catheterize
themselves, which as discussed above deviate from accepted medical care for
patients with SCI. I therefore request that CDC-NHSN add UTIs in SCI patients
to the list of UTIs that are excluded from a hospitalís CAUTI count, in a
similar manner that UTIs related to suprapubic catheters are excluded.
Respectfully submitted, Dr. Todd Linsenmeyer, MD (Submitted by: Kessler
Institute)
- [Pre-workgroup meeting comment] 12/5/14 Members of the MAP:
Hopefully you have seen and read the letter from the American Spinal Injury
Association (ASIA). Last March, a number of SCI specialists from respected SCI
centers across the country spoke out about this measure on the NQF website,
and I will include these comments in a separate post. They should also be
available to you in your records. Concerns about the use of so-called
ìpay-for-performanceî quality standards in healthcare have been raised by
groups such as the American Medical Association, American Academy of Family
Physicians, American College of Physicians, American Geriatrics Society, and
American Academy of Neurology. Concerns often center around the care of
medically complex patients who do not easily fit into simple treatment
paradigms. The plight of SCI patients and the CAUTI measure brings these
issues into clear focus. In patients with SCI, bladder overdistension is a
leading cause of Autonomic Dysreflexia (AD), a sympathetic storming event that
drives patientsí blood pressures into the Hypertensive Emergency range and can
produce stroke, seizures, and death. Following the transition toward
pay-for-performance for the CAUTI measure that occurred last October, SCI
specialists across the country have been seeing unprecedented rates of
inappropriate catheter removal and failure to implement adequate bladder
drainage in SCI patients. These patients are at risk for AD, UTI related to
urinary retention, hydronephrosis and renal failure. Most hospitals have
limited experience with SCI and are unprepared to manage SCI neurogenic
bladder without a foley. These hospitals are removing the foleys and are
watching their CAUTI rates decline, while other life- and health-threatening
consequences of this practice are going unrecognized and unreported. The
CDCís own document, ì GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY
TRACT INFECTIONS 2009,î the basis for the CAUTI measure, specifically
addresses the SCI patient population. The document states that the
recommendation to remove a foley from SCI patients is a Category II
recommendation (p. 11), that the evidence to support the recommendation is
ìvery low qualityî (p. 34), and that Category II recommendations are ìnot
intended to be enforcedî (p. 32). The CAUTI measure in its current form
violates both the CDCís own recommended guidelines as well as the Clinical
Practice Guidelines for Neurogenic Bladder in Spinal Cord Injury. The measure
is driving practices which are clearly unsafe for SCI patients. Furthermore,
in SCI patients, the measure fails at its primary objective of measuring UTIs,
since the definition of UTI used is not valid in patients with chronic
indwelling catheters and impaired bladder sensation. The plight of SCI
patients represents an unintended adverse consequence of the CAUTI measure.
This issue has been raised by SCI subspecialists around the country and so far
has been falling on deaf ears. When conducting research, if I encounter an
unintended adverse consequence, I am held accountable by an Institutional
Review Board. I see no such safety mechanism in place for pay-for-performance
quality measures. I understand that the NQF does not have the authority to
modify or strike down the CAUTI measure. I am simply asking that you withhold
your endorsement until this real and very serious issue is adequately
addressed. Thank you for your consideration. Matt Davis, MD TIRR Memorial
Hermann Clinical Director of SCI Services (Submitted by: TIRR Memorial
Hermann)
- [Pre-workgroup meeting comment] Last March, a number of SCI
specialists from respected SCI centers across the country spoke out about this
measure. I have pasted these comments here, for your review:
=============================== Submitted by Stephen Burns, MD I agree with
the comments of Drs. Alander, Stampas, Francisco, Gershkoff, Berliner, and
Davis. Indwelling catheters are the most appropriate management option for
many patients with neurogenic bladder dysfunction secondary to spinal cord
injury. They have been recommended as an option in the Consortium for Spinal
Cord Medicine's clinical practice guideline on management of neurogenic
bladder. They are usually the best choice for patients who lack hand function
(or cognitive function) to reliably perform self intermittent catheterization.
There is no significant difference in the rate of symptomatic urinary tract
infections with indwelling catheters compared to other options in patients
with severe neurogenic bladder dysfunction. I have personally seen adverse
outcomes when Foley catheters are inappropriately discontinued in patients
with SCI. A patient currently hospitalized on my service had this occur when
he was at an outside hospital. He was returned to his nursing home without a
catheter and was required to have a urinal balanced between his thighs 24
hours per day, since he had no ability to control urination. When we admitted
him, he had a post-void residual of 400ml. We immediately replaced the Foley
catheter and educated the patient on the appropriateness of this for managing
his bladder. It is not reasonable to expect providers outside of tertiary care
centers to have the knowledge to select optimal management for this condition.
I fear that encouraging them to discontinue catheter management will have a
negative impact on quality of life in this population with no health benefit
gained. For these reasons, exclusion of SCI patients from the numerator of NQF
#0138 is therefore justified. =============================== Submitted by
Monica Verduzco-Gutierrez, MD The CAUTI Outcome measure is an excellent
quality guideline in the abled body population. I take care of patients with
catastrophic injuries (spinal cord injuries and severe acquired brain
injuries) and in this patient population with neurogenic bladder, the
discontinuation of a foley can be injurious or deadly. Some centers are not
aware or able to manage a patient that necessitates a intermittent
catheterization program. These patients can be harmed by hydronephrosis, renal
failure, bladder rupture when a necessary foley is removed. I urge you to
consider excluding SCI patients from these guidelines or excluding speciality
rehabilitation hospitals from this measure. Thank you.
=============================== Submitted by Dirk H. Alander, MD I work in at
a level one trauma center (ACS, Illinois, Missouri) serving both the inner
city and large rural areas. I would move to avoid the inclusion of the SCI
patient into the population of patients using catheters. The SCI patient
population has a diverse range of injury patterns, associated injuries, and
social issues that do not lend themselves to the average patient with a short
term need of a catheter. Lack of adequate care outside of the acute and
rehabilitation hospitals is a real concern when patients are unable to
complete serial catheterizations and have little or no resources for
assistance. There needs to be much stronger evidence to support one method or
another before penalizing physicians, institutions and patients for urinary
tract infections after catheter use in this challenging patient population.
=============================== Submitted by Carolyn Tillquist Regarding
measure #0138 As an Infectious Diseases specialist practicing at Craig
Hospital for sci and brain injury patients, I deal with bacteriuria and utis
on a daily basis. We have been working at Craig to study these measures in
this population so as to better understand what best practices may be.
Although studies are in progress, both here and at other centers across the
nation, guidelines appropriate for these unique patients have not been
established. We know that the guidelines used to address the acute care
population, that are represented in measure #0138, do not apply. Please
exclude this population from this measure; including them in the current
measure would be a disservice to the patients and to those of us who have
dedicated our expertise to providing them with the best care possible.
Thank-you, Carolyn Tillquist,MD
========================================================================
Submitted by William Carter, III,MD I am relatively new to exposure to
larger spinal cord injury/ trauma centers. Prior to working in one, I had no
concept of how to manage bladder function in SCI. Afterwards, as mentioned by
others, there is a struggle even without such a policy for their bladder
management to be appropriate. In addition to spinal cord injury, this measure
could also adversely impact other populations such as multiple sclerosis,
polytrauma, and others. When transitioning from an indwelling catheter we
almost invariably place patients on fluid restriction of 2L/day. Without this
restriction, to maintain a safe bladder volume in someone unable to void,
intermittent catheterization would need to be performed more frequently and
there is no study that shows that doing intermittent catheterization every 3
hours is safer than an indwelling catheter. Furthermore, in the acute care
setting almost invariably patients are continued on IV fluids, IV antibiotics,
etc, contributing to more rapid bladder filling. Catheters are placed for
multiple reasons and if there is good documentation for why it needs to be
continued (too high fluid intake, inability to self cath, reasons that bladder
accidents can't be risked such as sacral pressure sores (not unique to SCI
population), etc) that should ideally suffice. I can recall from my internal
medicine training that all patients with heart failure were supposed to be
discharged on an ACE-I or ARB as a quality standard. However, if documentation
suggesting a contraindication was provided, there was no penalty. What is the
best way to make exceptions to the rule?
========================================================================
Submitted by Argyrios Stampas, MD Urinary tract infections are an unfortunate
risk when maintaining an indwelling catheter. However, they are a necessity
for many patients with spinal cord injury or disease secondary to the risk of
high bladder pressures and the subsequent kidney damage that will ensue.
Ideally, these patients would have an intermittent catheter schedule, which
is well known to reduce the amount of UTIs. However, for many patients, they
cannot self cath, nor can their loved ones or caregivers. They must rely on
health care providers. That said, a skilled nursing facility is ill-equipped
to catheterize patients every 4 - 6 hours. Without the bladder being
intermittently decompressed, the pressures can elevate leading to kidney
damage and/or infection. Thus, facilities must continue to use indwelling
catheters and treat the potential UTI, versus the alternative of renal
failure, pyelonephritis, and other far worse morbidities that may occur,
compared to a UTI.
========================================================================
Submitted by Lance Goetz I concur with the cements from other spinal cord
injury (SCI) professionals. Indwelling catheters (urethral or suprapubic) are
sometimes the only viable option for persons with SCI and some other causes of
neurogenic bladder dysfunction. Removal of an indwelling catheter and
placement of an external catheter could put such persons at risk for a number
of serious complications, including vesicoueretral reflux due to outlet
obstruction, leading to stone disease and/or kidney damage. Further,
insistence on intermittent catheterization could cause persons with SCI to be
denied admission to certain facilities. I recommend allowing justification of
indwelling catheter use or making other accommodations for these persons.
========================================================================
Submitted by Gerard Francisco The use of indwelling catheters in SCI patients
may actually represent the safest alternative and highest quality of life
possible. This was specifically addressed in the 2009 CDC CAUTI guidelines
(Gould 2009): ìFor patients with spinal cord injury, very low-quality evidence
suggested a benefit of avoiding indwelling urinary catheters. This was based
on a decreased risk of UTI and bacteriuria in those without indwelling
catheters (including patients managed with spontaneous voiding, clean
intermittent catheterization [CIC], and external striated sphincterotomy with
condom catheter drainage), as well as a lower risk of urinary complications,
including hematuria, stones, and urethral injury (fistula, erosion,
stricture).î Patients with limited dexterity or high level injuries have to
rely on caregivers to provide intermittent catherization every 4 hour which
may not be feasible or a deterent to returning to work or other activities.
The evidence on suprapubic tubes is not clear as a infection prevention
strategy. Over the course of time, these patients become naturally colonized
with benign organism(s) that does not represent an acute infection and likely
should not be treated with antibiotics. This colonization most likely helps
protect the patient from developing a UTI from pathogenic organisms, such as
those that are antibiotic resistant. Thus, I have concerns that the current
CDC definition and implementation by NHSN for CAUTI is currently
overestimating events in the SCI population and does not adequately address
the symptomology seen in these patients. The 2009 CDC CAUTI guidelines (Gould,
et al. , 2009) specifically recognized that 100% of patients with an
indwelling catheter for more than 30 days will have bacteriuria; therefore, it
would be expected for all long term catheter patients to have a colony count
in the urine. The preventative efforts outlined in NQF #0138 are appropriate
for the care of any indwelling catheter and we fully support the implementing
securing catheters to the leg, keeping collection bags below the level of the
bladder, and utilizing aseptic techniques for insertions. Our organization is
implementing programs to address these issues. Our concern is that these
efforts will only minimally impact infections because of the unique issues for
SCI patients as adequate research and evidence is lacking. Thus, I strongly
recommend: 1) Excluding SCI patients from the numerator of NQF #0138; 2)
Developing a SCI specific definition of CAUTI to better reflect the events in
this population; 3) Developing a specific measure on CAUTI for this population
to further the knowledge and advance the preventative efforts that are likely
to have a clinical impact for patients (ex: use of leg bags, closed vs open
symptoms, managing colonizations). Thank you. ===============================
Submitted by Arthur Maurice Gershkoff, M.D. I am concerned that the outcome
measure related to catheter associated urinary tract infections may impact
adversely on the medical care received by persons with spinal cord injuries
and other severe physical disabilities. Such patients may be at risk for
urinary incontinence with complications(such as skin irritation and impeding
of the healing of skin ulcers) or for urinary retention. The policy threatens
financial repercussions to hospitals with above-average rates of
catheter-associated urinary tract infections (CAUTIs). In response, many
facilities are making efforts to remove indwelling catheters in all patients ñ
often including SCI patients and other patients with severe physical
disabilities. These facilities may not be adequately educated or equipped to
successfully implement an intermittent catheterization program, and I have
been told that some patients are simply having condom catheters placed --
putting them at risk for obstructive uropathy and renal failure. While the
incentive to move to intermittent catheterizaton is admirable for most
patients, some patients are completely unable to tolerate this because of pain
or anatomic problems. For some patients, a hypertonic bladder or lower motor
neuron type bladder with a flaccid urinary sphincter and incontinence between
catheterizations, may also not be tolerable. For those patients, intermittent
catheterization is not an option, and indwelling Foley catheterization may be
required. It is inevitable that patients with long term indwelling Foley
catheters will eventually become colonized, and that some of these will go on
to develop infection. It would be important in the evaluation of CAUTI's, to
make sure that hospitals that have a large number of severely physically
disabled patients, such as rehabilitation hospitals, not be compared with
other hospitals that do not admit such patients (and instead, refer them
elsewhere.) If all hospitals are lumped together, there needs to be some risk
adjustment based on the percentage of severely disabled persons who are
admitted. Thank you for your consideration of this. Sincerely yours, Arthur M.
Gershkoff M.D. =============================== Submitted by Jeff Berliner, DO
Dear NHSN- I am from Craig Hospital, a model Spinal Cord System that
specializes in the delivery of outstanding care to those with spinal cord and
traumatic brain injuries. CAUTI's are a formidable opponent in those living
with spinal cord injury that rely on Foley or Intermittent Catheterization
Programs to drain the bladder. In acute inpatient rehabilitation a team
approach is used to teach those with either full or poor hand function to use
an intermittent catheter program to drain the bladder every four hours. Even
with the best of hygiene, CAUTI's are unavoidable in many of these patients.
They are learning to manipulate a catheter into their meatus to drain their
bladder and are repeatedly performing this action with-in a hospital setting
every four hours to learn to become independent. We use gloves, sterile
catheters and iodine every time but still to no avail as many come down with
UTIís. If a person has poor hand function then a catheter must remain in the
bladder and a caregiver must learn how to change and flush the Foley. What I
am asking for is an exclusion for this unique patient population. They, their
bladders and their means of elimination of urine do not fit the mold or the
spirit of the very people that this new guideline is trying to protect. This
new law may force clinicians in spinal cord injury to prescribe unneeded
antiobiotic prophylaxis for all patients to protect against a CAUTI. I will
ask our research department to come with facts about the frequency of UTIís in
this patient population. Thank you for this consideration- Dr. Berliner
=============================== Submitted by Matthew Davis, MD While seeking
to achieve a highly reliable healthcare system, it is important not to
overlook the needs of special populations. One such population is that of
people with disabilities ñ which has been designated as a minority group with
protection under items of legislation such as the Americans with Disabilities
Act. This concern leads me to request a modification of NQF #0138 (NHSN
Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure) to
specifically exclude patients with spinal cord injuries (SCI). Specific
considerations include: 1) A thorough review of studies measuring UTI rates in
SCI patients with indwelling catheters versus other means of bladder
management fails to demonstrate a consistent, clear, and statistically
significant benefit to removing indwelling catheters. 2) In an effort to
reduce CAUTI rates, acute care hospitals have been removing indwelling
catheters while failing to implement an adequate alternative form of bladder
management. This puts SCI patients at risk for obstructive uropathy and renal
failure. In the 2009 CDC CAUTI guidelines, Gould, et al, admits ìFor patients
with spinal cord injury, very low-quality evidence suggested a benefit of
avoiding indwelling urinary catheters.î Likewise, the Clinical Practice
Guidelines prepared by the Consortium for Spinal Cord Medicine in 2006
acknowledge that the data regarding rates of UTI in SCI patients with
indwelling catheters versus those using intermittent catheterization is
conflicting. In other words, there is not a clear, unequivocal benefit from
removing indwelling catheters in terms of reducing UTI risk. What is clear and
unequivocal, however, is that patients with acute SCI require adequate bladder
drainage ñ either through indwelling catheterization or through intermittent
catheterization. Intermittent catheterization must be done according to a
strict protocol in order to avoid obstructive uropathy and risk for renal
failure. Unfortunately, acute care hospitals are not well-versed in
implementing this protocol due to a low incidence of SCI patients in most
hospital settings. In the past few weeks, presumably due to concerns about
CAUTI rates, TIRR rehabilitation hospital has seen increasing numbers of
patients referred from acute care hospitals who have been transitioned to
diapers or condom catheters, a practice which puts patients at risk for
obstructive uropathy and acute renal failure. Our specific requests are: 1)
Exclude SCI patients from the numerator of NQF #0138 2) Develop a SCI-specific
definition of UTI to better reflect events in this population. This should be
done with input from board-certified specialists in spinal cord
medicine.(Submitted by: Various)
| (Program: Hospital Value-Based Purchasing Program; MUC ID:
S0138) |
- The Consumer-Purchaser Alliance is concerned about the recommended
condition that these measures be used in the Hospital Value-Based Purchasing
Program (HVBP)only following public reporting. We believe this condition
would only be appropriate as statutorily mandated. Moreover, we fully support
the swift and simultaneous implementation of these measures within the HVBP
program and across all other programs in which they are already in use. We
believe immediate implementation of the most recent version of the measure
will support continued alignment of measures across federal programs and
ensure that the most scientifically rigorous and up-to-date versions of
NQF-endorsed measures are implemented in a timely fashion. Additionally, we
would like to draw attention to results from the FY 2015 HVBP program, which
indicate that over 50% of eligible hospitals received payment incentives
through this program based on demonstrated performance. This figure
represents a rise in hospitals benefiting from the program from the year
prior, and we caution MAP against recommending an approach to measure updates
that might result in slowed progress or steps backwards from the success
achieved to date in improving health care quality.(Submitted by:
Consumer-Purchaser Alliance)
- [Pre-workgroup meeting comment] Patients with spinal cord injuries
(SCI) often require the use of indwelling catheters to manage their neurogenic
bladders. In an effort to comply with the publicly-reported CAUTI outcome
measure, some physicians who are treating SCI patients with indwelling
catheters are removing these catheters in direct conflict with the only
published clinical practice guideline on the subject (Linsenmayer, T. (Ed.)
Bladder Management for Adults with Spinal Cord Injury: A clinical practice
guideline for health-care providers. (Washington, DC: Consortium of Spinal
Cord Medicine, 2006).). This action may compromise the short- and long-term
health of the patient with SCI in ways that are unknown to the treating
physician and perhaps even the patients themselves. On behalf of patients
with spinal cord injuries, I respectfully ask that patients with spinal cord
injuries be administratively excluded from this outcome measure. While the
CAUTI measure is clinically appropriate for the general population, the
guidelines for SCI population indicate that catheters are the preferred
bladder management solution for certain SCI patients. Unfortunately, these
guidelines are unfamiliar to many physicians who see only small numbers of
patients with SCI; in ignorance of the published CPG, many physicians are
removing catheters inappropriately to comply with the CAUTI measure. The
authors of the CPG have been trying to raise awareness of the guidelines
existence for many years among the general physician population. This has been
to small avail; the SCI population is simply too small for every physician to
read and recall guidelines specific to this group. The CAUTI measure, on the
other hand, is driving clinical decision-making because it is
publicly-reported and tied (albeit indirectly) to reputation and ultimately
reimbursement. Specialists in the field of spinal cord medicine have come to
the consensus that indwelling catheters are appropriate for a portion of the
SCI population; we respectfully request that patients with spinal cord
injuries be administratively excluded from the CAUTI reporting guidelines as
the removal of indwelling catheters in this population follows a treatment
algorithm that differs from the general public and which is unknown to many
physicians who only treat the occasional patient with spinal cord injury.
(Submitted by: Quality of Life Advisors, Inc.)
- [Pre-workgroup meeting comment] The following is from a letter from
the president of the American Spinal Injury Association (ASIA), a professional
organization dedicated to the care of patients with Spinal Cord Injury (SCI).
This letter was approved by ASIAís board of directors prior to its release. I
have emailed a scanned copy of this letter, with letterhead and signature, to
Robert Saunders, senior director of the NQF: Drs. Frieden, Pollock, Gould,
and Pines: As care providers of patients with Spinal Cord Injuries (SCI), we
are seeing an alarming increase in the number of patients whose bladders are
managed in an unsafe manner following the transition last October toward ìPay
for Performanceî status of the National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure.
Hospitals' emphasis on removal of indwelling catheters is not surprising,
given the financial penalties involved and the public reporting of CAUTI rates
as an indicator of "quality healthcare." Unfortunately, most non-specialty
hospital settings are not adequately experienced in implementing an
intermittent catheterization (IC) program. Many physicians and nurses, in
fact, are not even aware of the need to perform IC in SCI patients. The
Consortium for Spinal Cord Medicine's Clinical Practice Guidelines for Bladder
Management for Adults with Spinal Cord Injury, one of the most definitive and
widely-accepted treatises on the subject, clearly indicate that indwelling
catheterization is preferable to poorly-implemented IC. While many of us
prefer suprapubic catheters to Foley catheters in the long term, this option
is simply not available in the first several weeks following SCI.
Additionally, the CAUTI measure focuses exclusively on UTI risk as the sole
consideration in selecting the method of bladder management in SCI. We believe
that indwelling catheterization remains a valuable option in a substantial
portion of SCI patients for a variety of reasons. Once again, these reasons
are outlined in the Clinical Practice Guidelines, which were assembled through
a rigorous review of the literature and of expert consensus by a team of
Neuro-Urologists, Certified Rehabilitation Nurses, and Physiatrists who
sub-specialize in SCI. Facilities which judiciously use indwelling catheters
are by no means providing substandard care. The public reporting of CAUTIs as
an indicator of "quality healthcare" in SCI patients adds insult to injury. It
risks leading patients and their families to facilities poorly equipped to
handle this catastrophic injury. Facilities without the insight to use
indwelling catheters judiciously will appear to be providing better care than
SCI specialty centers. Inadequately-implemented (or nonexistent) IC puts SCI
patients at risk for upper urinary tract deterioration, autonomic dysreflexia
(with resulting hypertensive emergency), and UTI related to urinary retention.
By indiscriminately removing Foley catheters, non-specialty hospitals can see
their CAUTI rates decline, while these life-threatening adverse consequences
are going unmeasured and unrecognized. One solution suggested by the CDC has
been that SCI physicians educate the medical community as a whole about how to
properly implement IC and how to identify which patients are appropriate for
continued foley use. Unfortunately, these are complicated decisions which are
usually made SCI sub-specialists working in tertiary care centers with
specialty-trained nurses. Most acute care nursing units see very few SCI
patients in a year. The operational feasibility of such a solution seems very
small, especially given the financial disincentives in place. The financial
penalty and public reporting of the CAUTI measure are driving practices which
deviate from acceptable medical care for patients with SCI. Accordingly, we
are requesting that CDC-NHSN add UTIs in SCI patients to the list of UTIs that
are excluded from a hospitalís CAUTI count, in a similar manner that UTIs
related to suprapubic catheters are excluded. Sincerely, Michael H. Haak, MD
ASIA President(Submitted by: American Spinal Injury Association
(ASIA))
- [Pre-workgroup meeting comment] I am comment on behalf of myself
and not representing Select Medical or Kessler Institute or PVA. I am the
Director of Urology at Kessler Institute for Rehabilitation and have been
working with SCI patients for the past 25 years. I am one of 2 urologists in
the country who is double boarded in Urology, Physical Medicine and
Rehabilitation as well as Spinal Cord Injury Medicine. I am the chairman of
the PVA SCI Consortium Guidelines on Bladder Management in Those With SCI. I
am also one of the committee members and authors of the recently published
International Data Set on UTIís in Those with SCI. While I think the
guidelines have a lot of merit in not leaving in a catheter in able bodied
individuals in an acute care hospital setting, I am very concerned with the
current CAUTI guidelines as they apply to those with indwelling catheters and
have an SCI. The financial penalty and public reporting of the CAUTI measure
encouraging the practice of removing a catheter in certain SCI individuals
which deviate from acceptable medical care for patients with SCI. Part of the
problem is that the definition of a UTI is very different in individuals with
SCI and neurogenic bladders compared to those who do not have a SCI.
Increased bacteria in the urine is considered to be the definition of a UTI in
non SCI, able bodied individuals. However, those with SCI WITH and WITHOUT an
indwelling catheter are routinely are colonized with bacteria in their
bladder. There is strong consensus that a person with a SCI should not be
considered to have an UTI just because of having bacteria in the bladder.
While there can be exceptions, 3 criteria need to be met to meet the
definition of a UTI in an individual with a SCI. These are; 1. bacteria in the
bladder (which almost all SCI individuals have), 2. increased WBCís in the
urine (that can occur from passing a catheter during intermittent
catheterization or an indwelling catheter) and very important, 3. the NEW
onset of symptoms. Our SCI bladder management consortium guidelines
(Linsenmeyer, T. (Ed.) Bladder Management for Adults with Spinal Cord Injury:
A clinical practice guideline for health-care providers. (Washington, DC:
Consortium of Spinal Cord Medicine, 2006).) specifically state that an
indwelling catheter should be considered in individuals who have poor hand
function and unable to catheterize themselves or do not have a willing
caregiver. This is because it is essential that the bladder is drained in a
timely manner. If a person is unable to catheterize themselves and the bladder
gets overdistended they can get a UTI or sepsis. In addition, if a person has
a SCI at T6 level or above (which includes those with poor hand function),
failure to drain the bladder can lead to a sudden severe potentially life
threatening rise in BP called autonomic dysreflexia. An indwelling catheter
is the safest way to keep this from happening. Also it is during the inpatient
setting that a person with a SCI and their family learn how to take care of
an indwelling catheter. If they are not taught how to manage an indwelling
catheter, the result is frequently to send a person home on intermittent
catheterization. The ìcaregiverî in most situations is a family member, so
that a wife or husband, mother or father has to suddenly take on the role of a
ìcaregiverî rather than a spouse, or a mother is now having to catheterize her
21 year old son around the clock. Intermittent catheterization requires
getting undressed so that a catheter can be passed down a persons urethra
every 4 to 6 hours and requires the trained person be available at all times
in case their bladder fills up quickly and the person with the SCI starts to
get autonomic dysreflexia. So now, as a result of having to perform
intermittent catheterization instead of having an indwelling catheter, both
the person with the SCI and person performing intermittent catheterization
need to be with each other at all times and causing both lose their
independence and have a significant decrease in their quality of life. This
is not the case with an indwelling catheter where there is a drainage bag
attached under the pants of the lower leg and can easily be reached and
drained by an untrained person by just twisting a small valve at the bottom of
the drainage bag. The other scenario is that a person with a long term SCI
and indwelling catheter is admitted to an acute care hospital for some medical
problem. The bladder becomes smaller with an indwelling catheter, and if it
were removed by a hospital staff that was not familiar with SCI in order to
decrease the risk of a financial penalty and public reporting of a CAUTI, the
SCI person would most certainly develop autonomic dysreflexia because of rapid
overdistention of their small bladder capacity. It should also be noted that
evaluation and management of acute autonomic dysreflexia is something that
most acute care hospital staff are not use to dealing with. In summary,
indwelling catheters for some SCI individuals is not only medically safer, but
allows a much better quality of life. The definitions of a UTI are also
different in those with an SCI. Under the definition of a UTI for able bodied
individual, almost all of our SCI patients who are colonized with bacteria,
with and without an indwelling catheter would be considered to have a UTI.
Those with an indwelling catheter would be classified as having a CAUTI.
Unfortunately, the financial penalty and public reporting of the CAUTI measure
are driving practices of removing catheters in those who cannot catheterize
themselves, which deviate from acceptable medical care for patients with SCI.
I therefore request that CDC-NHSN add UTIs in SCI patients to the list of
UTIs that are excluded from a hospitalís CAUTI count, in a similar manner that
UTIs related to suprapubic catheters are excluded. Respectfully submitted, Dr.
Todd Linsenmeyer, MD (Submitted by: Kessler Institute)
- [Pre-workgroup meeting comment] I have made a few minor editorial
changes from my comments recently submitted. Please use the following comment
instead. Thank you. T.L. I am commenting on behalf of myself and not
representing Select Medical or Kessler Institute or PVA. I am the Director of
Urology at Kessler Institute for Rehabilitation and have been working with SCI
patients for the past 25 years. I am one of 2 urologists in the country who is
double boarded in Urology, Physical Medicine and Rehabilitation as well as
Spinal Cord Injury Medicine. I am the chairman of the PVA SCI Consortium
Guidelines on Bladder Management in Those With SCI. I am also one of the
committee members and authors of the recently published International Data Set
on UTIís in Those with SCI. While I think the guidelines have a lot of merit
in not leaving in a catheter in able bodied individuals in an acute care
hospital setting, I am very concerned with the current CAUTI guidelines as
they apply to those with indwelling catheters and have an SCI. The financial
penalty and public reporting of the CAUTI measure are encouraging the practice
of removing catheters in certain SCI individuals, which deviate from accepted
medical care for patients with SCI. Part of the problem is that the
definition of a UTI is very different in individuals with SCI and neurogenic
bladders compared to those who do not have a SCI. Increased bacteria in the
urine is considered to be the definition of a UTI in non SCI, able bodied
individuals. However, those with SCI WITH and WITHOUT an indwelling catheter
are routinely are colonized with bacteria in their bladder. There is strong
consensus that a person with a SCI should not be considered to have an UTI
just because of having bacteria in the bladder. While there can be
exceptions, 3 criteria need to be met to meet the definition of a UTI in an
individual with a SCI. These are; 1. bacteria in the bladder (which almost all
SCI individuals have), 2. increased WBCís in the urine (that can occur from
passing a catheter during intermittent catheterization or an indwelling
catheter) and very important, 3. the NEW onset of symptoms. Our SCI bladder
management consortium guidelines (Linsenmeyer, T. (Ed.) Bladder Management
for Adults with Spinal Cord Injury: A clinical practice guideline for
health-care providers. (Washington, DC: Consortium of Spinal Cord Medicine,
2006) specifically state that an indwelling catheter should be considered in
individuals who have poor hand function and unable to catheterize themselves
or do not have a willing caregiver. This is because it is essential that the
bladder is drained in a timely manner. If a person is unable to catheterize
themselves and the bladder gets over distended they can get a UTI or sepsis.
In addition, if a person has a SCI at T6 level or above (which includes those
with poor hand function), failure to drain the bladder can lead to a sudden
severe potentially life threatening rise in BP called autonomic dysreflexia.
An indwelling catheter is the safest way to keep this from happening. Also it
is during the inpatient setting that a person with a SCI and their family
learns how to take care of an indwelling catheter. If they are not taught how
to manage an indwelling catheter, the result is frequently to send a person
home on intermittent catheterization. The ìcaregiverî in most situations is a
family member, so that a wife or husband, mother or father has to suddenly
take on the role of a ìcaregiverî rather than a spouse, or a mother now has to
catheterize her 21 year old son around the clock. Intermittent
catheterization requires getting undressed so that a catheter can be passed
down a personís urethra every 4 to 6 hours and requires the trained person be
available at all times in case their bladder fills up quickly and the person
with the SCI starts to get autonomic dysreflexia. So now, as a result of
having to perform intermittent catheterization instead of having an indwelling
catheter, both the person with the SCI and person performing intermittent
catheterization need to be with each other at all times and causing both lose
their independence and have a significant decrease in their quality of life.
This is not the case with an indwelling catheter where there is a drainage
bag attached under the pants of the lower part of the leg and can easily be
reached and drained even by an untrained person by just twisting a small
valve at the bottom of the drainage bag. Another scenario is that a person
with a long term SCI and indwelling catheter is admitted to an acute care
hospital for a non UTI medical problem. The bladder becomes smaller with an
indwelling catheter, and if it were removed by a hospital staff that was not
familiar with SCI, in order to decrease the risk of a financial penalty and
public reporting of a CAUTI, the SCI person would most certainly develop
autonomic dysreflexia due to rapid over distention of their small bladder
capacity. It should also be noted that evaluation and management of acute
autonomic dysreflexia is something that most acute care hospital staff are not
use to dealing with. In summary, indwelling catheters for some SCI
individuals are not only medically safer, but allow a much better quality of
life. Under the definition of a UTI for able bodied individual, almost all of
our SCI patients who are colonized with bacteria, with and without an
indwelling catheter would be considered to have a UTI. Those with an
indwelling catheter would be classified as having a CAUTI. Unfortunately, the
financial penalty and public reporting of the CAUTI measure are driving
practices of removing catheters in those with SCI who cannot catheterize
themselves, which as discussed above deviate from accepted medical care for
patients with SCI. I therefore request that CDC-NHSN add UTIs in SCI patients
to the list of UTIs that are excluded from a hospitalís CAUTI count, in a
similar manner that UTIs related to suprapubic catheters are excluded.
Respectfully submitted, Dr. Todd Linsenmeyer, MD (Submitted by: Kessler
Institute)
- [Pre-workgroup meeting comment] 12/5/14 Members of the MAP:
Hopefully you have seen and read the letter from the American Spinal Injury
Association (ASIA). Last March, a number of SCI specialists from respected SCI
centers across the country spoke out about this measure on the NQF website,
and I will include these comments in a separate post. They should also be
available to you in your records. Concerns about the use of so-called
ìpay-for-performanceî quality standards in healthcare have been raised by
groups such as the American Medical Association, American Academy of Family
Physicians, American College of Physicians, American Geriatrics Society, and
American Academy of Neurology. Concerns often center around the care of
medically complex patients who do not easily fit into simple treatment
paradigms. The plight of SCI patients and the CAUTI measure brings these
issues into clear focus. In patients with SCI, bladder overdistension is a
leading cause of Autonomic Dysreflexia (AD), a sympathetic storming event that
drives patientsí blood pressures into the Hypertensive Emergency range and can
produce stroke, seizures, and death. Following the transition toward
pay-for-performance for the CAUTI measure that occurred last October, SCI
specialists across the country have been seeing unprecedented rates of
inappropriate catheter removal and failure to implement adequate bladder
drainage in SCI patients. These patients are at risk for AD, UTI related to
urinary retention, hydronephrosis and renal failure. Most hospitals have
limited experience with SCI and are unprepared to manage SCI neurogenic
bladder without a foley. These hospitals are removing the foleys and are
watching their CAUTI rates decline, while other life- and health-threatening
consequences of this practice are going unrecognized and unreported. The
CDCís own document, ì GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY
TRACT INFECTIONS 2009,î the basis for the CAUTI measure, specifically
addresses the SCI patient population. The document states that the
recommendation to remove a foley from SCI patients is a Category II
recommendation (p. 11), that the evidence to support the recommendation is
ìvery low qualityî (p. 34), and that Category II recommendations are ìnot
intended to be enforcedî (p. 32). The CAUTI measure in its current form
violates both the CDCís own recommended guidelines as well as the Clinical
Practice Guidelines for Neurogenic Bladder in Spinal Cord Injury. The measure
is driving practices which are clearly unsafe for SCI patients. Furthermore,
in SCI patients, the measure fails at its primary objective of measuring UTIs,
since the definition of UTI used is not valid in patients with chronic
indwelling catheters and impaired bladder sensation. The plight of SCI
patients represents an unintended adverse consequence of the CAUTI measure.
This issue has been raised by SCI subspecialists around the country and so far
has been falling on deaf ears. When conducting research, if I encounter an
unintended adverse consequence, I am held accountable by an Institutional
Review Board. I see no such safety mechanism in place for pay-for-performance
quality measures. I understand that the NQF does not have the authority to
modify or strike down the CAUTI measure. I am simply asking that you withhold
your endorsement until this real and very serious issue is adequately
addressed. Thank you for your consideration. Matt Davis, MD TIRR Memorial
Hermann Clinical Director of SCI Services (Submitted by: TIRR Memorial
Hermann)
- [Pre-workgroup meeting comment] Last March, a number of SCI
specialists from respected SCI centers across the country spoke out about this
measure. I have pasted these comments here, for your review:
=============================== Submitted by Stephen Burns, MD I agree with
the comments of Drs. Alander, Stampas, Francisco, Gershkoff, Berliner, and
Davis. Indwelling catheters are the most appropriate management option for
many patients with neurogenic bladder dysfunction secondary to spinal cord
injury. They have been recommended as an option in the Consortium for Spinal
Cord Medicine's clinical practice guideline on management of neurogenic
bladder. They are usually the best choice for patients who lack hand function
(or cognitive function) to reliably perform self intermittent catheterization.
There is no significant difference in the rate of symptomatic urinary tract
infections with indwelling catheters compared to other options in patients
with severe neurogenic bladder dysfunction. I have personally seen adverse
outcomes when Foley catheters are inappropriately discontinued in patients
with SCI. A patient currently hospitalized on my service had this occur when
he was at an outside hospital. He was returned to his nursing home without a
catheter and was required to have a urinal balanced between his thighs 24
hours per day, since he had no ability to control urination. When we admitted
him, he had a post-void residual of 400ml. We immediately replaced the Foley
catheter and educated the patient on the appropriateness of this for managing
his bladder. It is not reasonable to expect providers outside of tertiary care
centers to have the knowledge to select optimal management for this condition.
I fear that encouraging them to discontinue catheter management will have a
negative impact on quality of life in this population with no health benefit
gained. For these reasons, exclusion of SCI patients from the numerator of NQF
#0138 is therefore justified. =============================== Submitted by
Monica Verduzco-Gutierrez, MD The CAUTI Outcome measure is an excellent
quality guideline in the abled body population. I take care of patients with
catastrophic injuries (spinal cord injuries and severe acquired brain
injuries) and in this patient population with neurogenic bladder, the
discontinuation of a foley can be injurious or deadly. Some centers are not
aware or able to manage a patient that necessitates a intermittent
catheterization program. These patients can be harmed by hydronephrosis, renal
failure, bladder rupture when a necessary foley is removed. I urge you to
consider excluding SCI patients from these guidelines or excluding speciality
rehabilitation hospitals from this measure. Thank you.
=============================== Submitted by Dirk H. Alander, MD I work in at
a level one trauma center (ACS, Illinois, Missouri) serving both the inner
city and large rural areas. I would move to avoid the inclusion of the SCI
patient into the population of patients using catheters. The SCI patient
population has a diverse range of injury patterns, associated injuries, and
social issues that do not lend themselves to the average patient with a short
term need of a catheter. Lack of adequate care outside of the acute and
rehabilitation hospitals is a real concern when patients are unable to
complete serial catheterizations and have little or no resources for
assistance. There needs to be much stronger evidence to support one method or
another before penalizing physicians, institutions and patients for urinary
tract infections after catheter use in this challenging patient population.
=============================== Submitted by Carolyn Tillquist Regarding
measure #0138 As an Infectious Diseases specialist practicing at Craig
Hospital for sci and brain injury patients, I deal with bacteriuria and utis
on a daily basis. We have been working at Craig to study these measures in
this population so as to better understand what best practices may be.
Although studies are in progress, both here and at other centers across the
nation, guidelines appropriate for these unique patients have not been
established. We know that the guidelines used to address the acute care
population, that are represented in measure #0138, do not apply. Please
exclude this population from this measure; including them in the current
measure would be a disservice to the patients and to those of us who have
dedicated our expertise to providing them with the best care possible.
Thank-you, Carolyn Tillquist,MD
========================================================================
Submitted by William Carter, III,MD I am relatively new to exposure to
larger spinal cord injury/ trauma centers. Prior to working in one, I had no
concept of how to manage bladder function in SCI. Afterwards, as mentioned by
others, there is a struggle even without such a policy for their bladder
management to be appropriate. In addition to spinal cord injury, this measure
could also adversely impact other populations such as multiple sclerosis,
polytrauma, and others. When transitioning from an indwelling catheter we
almost invariably place patients on fluid restriction of 2L/day. Without this
restriction, to maintain a safe bladder volume in someone unable to void,
intermittent catheterization would need to be performed more frequently and
there is no study that shows that doing intermittent catheterization every 3
hours is safer than an indwelling catheter. Furthermore, in the acute care
setting almost invariably patients are continued on IV fluids, IV antibiotics,
etc, contributing to more rapid bladder filling. Catheters are placed for
multiple reasons and if there is good documentation for why it needs to be
continued (too high fluid intake, inability to self cath, reasons that bladder
accidents can't be risked such as sacral pressure sores (not unique to SCI
population), etc) that should ideally suffice. I can recall from my internal
medicine training that all patients with heart failure were supposed to be
discharged on an ACE-I or ARB as a quality standard. However, if documentation
suggesting a contraindication was provided, there was no penalty. What is the
best way to make exceptions to the rule?
========================================================================
Submitted by Argyrios Stampas, MD Urinary tract infections are an unfortunate
risk when maintaining an indwelling catheter. However, they are a necessity
for many patients with spinal cord injury or disease secondary to the risk of
high bladder pressures and the subsequent kidney damage that will ensue.
Ideally, these patients would have an intermittent catheter schedule, which
is well known to reduce the amount of UTIs. However, for many patients, they
cannot self cath, nor can their loved ones or caregivers. They must rely on
health care providers. That said, a skilled nursing facility is ill-equipped
to catheterize patients every 4 - 6 hours. Without the bladder being
intermittently decompressed, the pressures can elevate leading to kidney
damage and/or infection. Thus, facilities must continue to use indwelling
catheters and treat the potential UTI, versus the alternative of renal
failure, pyelonephritis, and other far worse morbidities that may occur,
compared to a UTI.
========================================================================
Submitted by Lance Goetz I concur with the cements from other spinal cord
injury (SCI) professionals. Indwelling catheters (urethral or suprapubic) are
sometimes the only viable option for persons with SCI and some other causes of
neurogenic bladder dysfunction. Removal of an indwelling catheter and
placement of an external catheter could put such persons at risk for a number
of serious complications, including vesicoueretral reflux due to outlet
obstruction, leading to stone disease and/or kidney damage. Further,
insistence on intermittent catheterization could cause persons with SCI to be
denied admission to certain facilities. I recommend allowing justification of
indwelling catheter use or making other accommodations for these persons.
========================================================================
Submitted by Gerard Francisco The use of indwelling catheters in SCI patients
may actually represent the safest alternative and highest quality of life
possible. This was specifically addressed in the 2009 CDC CAUTI guidelines
(Gould 2009): ìFor patients with spinal cord injury, very low-quality evidence
suggested a benefit of avoiding indwelling urinary catheters. This was based
on a decreased risk of UTI and bacteriuria in those without indwelling
catheters (including patients managed with spontaneous voiding, clean
intermittent catheterization [CIC], and external striated sphincterotomy with
condom catheter drainage), as well as a lower risk of urinary complications,
including hematuria, stones, and urethral injury (fistula, erosion,
stricture).î Patients with limited dexterity or high level injuries have to
rely on caregivers to provide intermittent catherization every 4 hour which
may not be feasible or a deterent to returning to work or other activities.
The evidence on suprapubic tubes is not clear as a infection prevention
strategy. Over the course of time, these patients become naturally colonized
with benign organism(s) that does not represent an acute infection and likely
should not be treated with antibiotics. This colonization most likely helps
protect the patient from developing a UTI from pathogenic organisms, such as
those that are antibiotic resistant. Thus, I have concerns that the current
CDC definition and implementation by NHSN for CAUTI is currently
overestimating events in the SCI population and does not adequately address
the symptomology seen in these patients. The 2009 CDC CAUTI guidelines (Gould,
et al. , 2009) specifically recognized that 100% of patients with an
indwelling catheter for more than 30 days will have bacteriuria; therefore, it
would be expected for all long term catheter patients to have a colony count
in the urine. The preventative efforts outlined in NQF #0138 are appropriate
for the care of any indwelling catheter and we fully support the implementing
securing catheters to the leg, keeping collection bags below the level of the
bladder, and utilizing aseptic techniques for insertions. Our organization is
implementing programs to address these issues. Our concern is that these
efforts will only minimally impact infections because of the unique issues for
SCI patients as adequate research and evidence is lacking. Thus, I strongly
recommend: 1) Excluding SCI patients from the numerator of NQF #0138; 2)
Developing a SCI specific definition of CAUTI to better reflect the events in
this population; 3) Developing a specific measure on CAUTI for this population
to further the knowledge and advance the preventative efforts that are likely
to have a clinical impact for patients (ex: use of leg bags, closed vs open
symptoms, managing colonizations). Thank you. ===============================
Submitted by Arthur Maurice Gershkoff, M.D. I am concerned that the outcome
measure related to catheter associated urinary tract infections may impact
adversely on the medical care received by persons with spinal cord injuries
and other severe physical disabilities. Such patients may be at risk for
urinary incontinence with complications(such as skin irritation and impeding
of the healing of skin ulcers) or for urinary retention. The policy threatens
financial repercussions to hospitals with above-average rates of
catheter-associated urinary tract infections (CAUTIs). In response, many
facilities are making efforts to remove indwelling catheters in all patients ñ
often including SCI patients and other patients with severe physical
disabilities. These facilities may not be adequately educated or equipped to
successfully implement an intermittent catheterization program, and I have
been told that some patients are simply having condom catheters placed --
putting them at risk for obstructive uropathy and renal failure. While the
incentive to move to intermittent catheterizaton is admirable for most
patients, some patients are completely unable to tolerate this because of pain
or anatomic problems. For some patients, a hypertonic bladder or lower motor
neuron type bladder with a flaccid urinary sphincter and incontinence between
catheterizations, may also not be tolerable. For those patients, intermittent
catheterization is not an option, and indwelling Foley catheterization may be
required. It is inevitable that patients with long term indwelling Foley
catheters will eventually become colonized, and that some of these will go on
to develop infection. It would be important in the evaluation of CAUTI's, to
make sure that hospitals that have a large number of severely physically
disabled patients, such as rehabilitation hospitals, not be compared with
other hospitals that do not admit such patients (and instead, refer them
elsewhere.) If all hospitals are lumped together, there needs to be some risk
adjustment based on the percentage of severely disabled persons who are
admitted. Thank you for your consideration of this. Sincerely yours, Arthur M.
Gershkoff M.D. =============================== Submitted by Jeff Berliner, DO
Dear NHSN- I am from Craig Hospital, a model Spinal Cord System that
specializes in the delivery of outstanding care to those with spinal cord and
traumatic brain injuries. CAUTI's are a formidable opponent in those living
with spinal cord injury that rely on Foley or Intermittent Catheterization
Programs to drain the bladder. In acute inpatient rehabilitation a team
approach is used to teach those with either full or poor hand function to use
an intermittent catheter program to drain the bladder every four hours. Even
with the best of hygiene, CAUTI's are unavoidable in many of these patients.
They are learning to manipulate a catheter into their meatus to drain their
bladder and are repeatedly performing this action with-in a hospital setting
every four hours to learn to become independent. We use gloves, sterile
catheters and iodine every time but still to no avail as many come down with
UTIís. If a person has poor hand function then a catheter must remain in the
bladder and a caregiver must learn how to change and flush the Foley. What I
am asking for is an exclusion for this unique patient population. They, their
bladders and their means of elimination of urine do not fit the mold or the
spirit of the very people that this new guideline is trying to protect. This
new law may force clinicians in spinal cord injury to prescribe unneeded
antiobiotic prophylaxis for all patients to protect against a CAUTI. I will
ask our research department to come with facts about the frequency of UTIís in
this patient population. Thank you for this consideration- Dr. Berliner
=============================== Submitted by Matthew Davis, MD While seeking
to achieve a highly reliable healthcare system, it is important not to
overlook the needs of special populations. One such population is that of
people with disabilities ñ which has been designated as a minority group with
protection under items of legislation such as the Americans with Disabilities
Act. This concern leads me to request a modification of NQF #0138 (NHSN
Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure) to
specifically exclude patients with spinal cord injuries (SCI). Specific
considerations include: 1) A thorough review of studies measuring UTI rates in
SCI patients with indwelling catheters versus other means of bladder
management fails to demonstrate a consistent, clear, and statistically
significant benefit to removing indwelling catheters. 2) In an effort to
reduce CAUTI rates, acute care hospitals have been removing indwelling
catheters while failing to implement an adequate alternative form of bladder
management. This puts SCI patients at risk for obstructive uropathy and renal
failure. In the 2009 CDC CAUTI guidelines, Gould, et al, admits ìFor patients
with spinal cord injury, very low-quality evidence suggested a benefit of
avoiding indwelling urinary catheters.î Likewise, the Clinical Practice
Guidelines prepared by the Consortium for Spinal Cord Medicine in 2006
acknowledge that the data regarding rates of UTI in SCI patients with
indwelling catheters versus those using intermittent catheterization is
conflicting. In other words, there is not a clear, unequivocal benefit from
removing indwelling catheters in terms of reducing UTI risk. What is clear and
unequivocal, however, is that patients with acute SCI require adequate bladder
drainage ñ either through indwelling catheterization or through intermittent
catheterization. Intermittent catheterization must be done according to a
strict protocol in order to avoid obstructive uropathy and risk for renal
failure. Unfortunately, acute care hospitals are not well-versed in
implementing this protocol due to a low incidence of SCI patients in most
hospital settings. In the past few weeks, presumably due to concerns about
CAUTI rates, TIRR rehabilitation hospital has seen increasing numbers of
patients referred from acute care hospitals who have been transitioned to
diapers or condom catheters, a practice which puts patients at risk for
obstructive uropathy and acute renal failure. Our specific requests are: 1)
Exclude SCI patients from the numerator of NQF #0138 2) Develop a SCI-specific
definition of UTI to better reflect events in this population. This should be
done with input from board-certified specialists in spinal cord
medicine.(Submitted by: various)
| (Program: Inpatient Quality Reporting Program ; MUC ID: S0138)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- [Pre-workgroup meeting comment] Patients with spinal cord injuries
(SCI) often require the use of indwelling catheters to manage their neurogenic
bladders. In an effort to comply with the publicly-reported CAUTI outcome
measure, some physicians who are treating SCI patients with indwelling
catheters are removing these catheters in direct conflict with the only
published clinical practice guideline on the subject (Linsenmayer, T. (Ed.)
Bladder Management for Adults with Spinal Cord Injury: A clinical practice
guideline for health-care providers. (Washington, DC: Consortium of Spinal
Cord Medicine, 2006).). This action may compromise the short- and long-term
health of the patient with SCI in ways that are unknown to the treating
physician and perhaps even the patients themselves. On behalf of patients
with spinal cord injuries, I respectfully ask that patients with spinal cord
injuries be administratively excluded from this outcome measure. While the
CAUTI measure is clinically appropriate for the general population, the
guidelines for SCI population indicate that catheters are the preferred
bladder management solution for certain SCI patients. Unfortunately, these
guidelines are unfamiliar to many physicians who see only small numbers of
patients with SCI; in ignorance of the published CPG, many physicians are
removing catheters inappropriately to comply with the CAUTI measure. The
authors of the CPG have been trying to raise awareness of the guidelines
existence for many years among the general physician population. This has been
to small avail; the SCI population is simply too small for every physician to
read and recall guidelines specific to this group. The CAUTI measure, on the
other hand, is driving clinical decision-making because it is
publicly-reported and tied (albeit indirectly) to reputation and ultimately
reimbursement. Specialists in the field of spinal cord medicine have come to
the consensus that indwelling catheters are appropriate for a portion of the
SCI population; we respectfully request that patients with spinal cord
injuries be administratively excluded from the CAUTI reporting guidelines as
the removal of indwelling catheters in this population follows a treatment
algorithm that differs from the general public and which is unknown to many
physicians who only treat the occasional patient with spinal cord injury.
(Submitted by: Quality of Life Advisors, Inc.)
- [Pre-workgroup meeting comment] The following is from a letter from
the president of the American Spinal Injury Association (ASIA), a professional
organization dedicated to the care of patients with Spinal Cord Injury (SCI).
This letter was approved by ASIAís board of directors prior to its release. I
have emailed a scanned copy of this letter, with letterhead and signature, to
Robert Saunders, senior director of the NQF: Drs. Frieden, Pollock, Gould,
and Pines: As care providers of patients with Spinal Cord Injuries (SCI), we
are seeing an alarming increase in the number of patients whose bladders are
managed in an unsafe manner following the transition last October toward ìPay
for Performanceî status of the National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure.
Hospitals' emphasis on removal of indwelling catheters is not surprising,
given the financial penalties involved and the public reporting of CAUTI rates
as an indicator of "quality healthcare." Unfortunately, most non-specialty
hospital settings are not adequately experienced in implementing an
intermittent catheterization (IC) program. Many physicians and nurses, in
fact, are not even aware of the need to perform IC in SCI patients. The
Consortium for Spinal Cord Medicine's Clinical Practice Guidelines for Bladder
Management for Adults with Spinal Cord Injury, one of the most definitive and
widely-accepted treatises on the subject, clearly indicate that indwelling
catheterization is preferable to poorly-implemented IC. While many of us
prefer suprapubic catheters to Foley catheters in the long term, this option
is simply not available in the first several weeks following SCI.
Additionally, the CAUTI measure focuses exclusively on UTI risk as the sole
consideration in selecting the method of bladder management in SCI. We believe
that indwelling catheterization remains a valuable option in a substantial
portion of SCI patients for a variety of reasons. Once again, these reasons
are outlined in the Clinical Practice Guidelines, which were assembled through
a rigorous review of the literature and of expert consensus by a team of
Neuro-Urologists, Certified Rehabilitation Nurses, and Physiatrists who
sub-specialize in SCI. Facilities which judiciously use indwelling catheters
are by no means providing substandard care. The public reporting of CAUTIs as
an indicator of "quality healthcare" in SCI patients adds insult to injury. It
risks leading patients and their families to facilities poorly equipped to
handle this catastrophic injury. Facilities without the insight to use
indwelling catheters judiciously will appear to be providing better care than
SCI specialty centers. Inadequately-implemented (or nonexistent) IC puts SCI
patients at risk for upper urinary tract deterioration, autonomic dysreflexia
(with resulting hypertensive emergency), and UTI related to urinary retention.
By indiscriminately removing Foley catheters, non-specialty hospitals can see
their CAUTI rates decline, while these life-threatening adverse consequences
are going unmeasured and unrecognized. One solution suggested by the CDC has
been that SCI physicians educate the medical community as a whole about how to
properly implement IC and how to identify which patients are appropriate for
continued foley use. Unfortunately, these are complicated decisions which are
usually made SCI sub-specialists working in tertiary care centers with
specialty-trained nurses. Most acute care nursing units see very few SCI
patients in a year. The operational feasibility of such a solution seems very
small, especially given the financial disincentives in place. The financial
penalty and public reporting of the CAUTI measure are driving practices which
deviate from acceptable medical care for patients with SCI. Accordingly, we
are requesting that CDC-NHSN add UTIs in SCI patients to the list of UTIs that
are excluded from a hospitalís CAUTI count, in a similar manner that UTIs
related to suprapubic catheters are excluded. Sincerely, Michael H. Haak, MD
ASIA President(Submitted by: American Spinal Injury Association
(ASIA))
- [Pre-workgroup meeting comment] I have made a few minor editorial
changes from my comments recently submitted. Please use the following comment
instead. Thank you. T.L. I am commenting on behalf of myself and not
representing Select Medical or Kessler Institute or PVA. I am the Director of
Urology at Kessler Institute for Rehabilitation and have been working with SCI
patients for the past 25 years. I am one of 2 urologists in the country who is
double boarded in Urology, Physical Medicine and Rehabilitation as well as
Spinal Cord Injury Medicine. I am the chairman of the PVA SCI Consortium
Guidelines on Bladder Management in Those With SCI. I am also one of the
committee members and authors of the recently published International Data Set
on UTIís in Those with SCI. While I think the guidelines have a lot of merit
in not leaving in a catheter in able bodied individuals in an acute care
hospital setting, I am very concerned with the current CAUTI guidelines as
they apply to those with indwelling catheters and have an SCI. The financial
penalty and public reporting of the CAUTI measure are encouraging the practice
of removing catheters in certain SCI individuals, which deviate from accepted
medical care for patients with SCI. Part of the problem is that the
definition of a UTI is very different in individuals with SCI and neurogenic
bladders compared to those who do not have a SCI. Increased bacteria in the
urine is considered to be the definition of a UTI in non SCI, able bodied
individuals. However, those with SCI WITH and WITHOUT an indwelling catheter
are routinely are colonized with bacteria in their bladder. There is strong
consensus that a person with a SCI should not be considered to have an UTI
just because of having bacteria in the bladder. While there can be
exceptions, 3 criteria need to be met to meet the definition of a UTI in an
individual with a SCI. These are; 1. bacteria in the bladder (which almost all
SCI individuals have), 2. increased WBCís in the urine (that can occur from
passing a catheter during intermittent catheterization or an indwelling
catheter) and very important, 3. the NEW onset of symptoms. Our SCI bladder
management consortium guidelines (Linsenmeyer, T. (Ed.) Bladder Management
for Adults with Spinal Cord Injury: A clinical practice guideline for
health-care providers. (Washington, DC: Consortium of Spinal Cord Medicine,
2006) specifically state that an indwelling catheter should be considered in
individuals who have poor hand function and unable to catheterize themselves
or do not have a willing caregiver. This is because it is essential that the
bladder is drained in a timely manner. If a person is unable to catheterize
themselves and the bladder gets over distended they can get a UTI or sepsis.
In addition, if a person has a SCI at T6 level or above (which includes those
with poor hand function), failure to drain the bladder can lead to a sudden
severe potentially life threatening rise in BP called autonomic dysreflexia.
An indwelling catheter is the safest way to keep this from happening. Also it
is during the inpatient setting that a person with a SCI and their family
learns how to take care of an indwelling catheter. If they are not taught how
to manage an indwelling catheter, the result is frequently to send a person
home on intermittent catheterization. The ìcaregiverî in most situations is a
family member, so that a wife or husband, mother or father has to suddenly
take on the role of a ìcaregiverî rather than a spouse, or a mother now has to
catheterize her 21 year old son around the clock. Intermittent
catheterization requires getting undressed so that a catheter can be passed
down a personís urethra every 4 to 6 hours and requires the trained person be
available at all times in case their bladder fills up quickly and the person
with the SCI starts to get autonomic dysreflexia. So now, as a result of
having to perform intermittent catheterization instead of having an indwelling
catheter, both the person with the SCI and person performing intermittent
catheterization need to be with each other at all times and causing both lose
their independence and have a significant decrease in their quality of life.
This is not the case with an indwelling catheter where there is a drainage
bag attached under the pants of the lower part of the leg and can easily be
reached and drained even by an untrained person by just twisting a small
valve at the bottom of the drainage bag. Another scenario is that a person
with a long term SCI and indwelling catheter is admitted to an acute care
hospital for a non UTI medical problem. The bladder becomes smaller with an
indwelling catheter, and if it were removed by a hospital staff that was not
familiar with SCI, in order to decrease the risk of a financial penalty and
public reporting of a CAUTI, the SCI person would most certainly develop
autonomic dysreflexia due to rapid over distention of their small bladder
capacity. It should also be noted that evaluation and management of acute
autonomic dysreflexia is something that most acute care hospital staff are not
use to dealing with. In summary, indwelling catheters for some SCI
individuals are not only medically safer, but allow a much better quality of
life. Under the definition of a UTI for able bodied individual, almost all of
our SCI patients who are colonized with bacteria, with and without an
indwelling catheter would be considered to have a UTI. Those with an
indwelling catheter would be classified as having a CAUTI. Unfortunately, the
financial penalty and public reporting of the CAUTI measure are driving
practices of removing catheters in those with SCI who cannot catheterize
themselves, which as discussed above deviate from accepted medical care for
patients with SCI. I therefore request that CDC-NHSN add UTIs in SCI patients
to the list of UTIs that are excluded from a hospitalís CAUTI count, in a
similar manner that UTIs related to suprapubic catheters are excluded.
Respectfully submitted, Dr. Todd Linsenmeyer, MD (Submitted by: Kessler
Institute)
- [Pre-workgroup meeting comment] 12/5/14 Members of the MAP:
Hopefully you have seen and read the letter from the American Spinal Injury
Association (ASIA). Last March, a number of SCI specialists from respected SCI
centers across the country spoke out about this measure on the NQF website,
and I will include these comments in a separate post. They should also be
available to you in your records. Concerns about the use of so-called
ìpay-for-performanceî quality standards in healthcare have been raised by
groups such as the American Medical Association, American Academy of Family
Physicians, American College of Physicians, American Geriatrics Society, and
American Academy of Neurology. Concerns often center around the care of
medically complex patients who do not easily fit into simple treatment
paradigms. The plight of SCI patients and the CAUTI measure brings these
issues into clear focus. In patients with SCI, bladder overdistension is a
leading cause of Autonomic Dysreflexia (AD), a sympathetic storming event that
drives patientsí blood pressures into the Hypertensive Emergency range and can
produce stroke, seizures, and death. Following the transition toward
pay-for-performance for the CAUTI measure that occurred last October, SCI
specialists across the country have been seeing unprecedented rates of
inappropriate catheter removal and failure to implement adequate bladder
drainage in SCI patients. These patients are at risk for AD, UTI related to
urinary retention, hydronephrosis and renal failure. Most hospitals have
limited experience with SCI and are unprepared to manage SCI neurogenic
bladder without a foley. These hospitals are removing the foleys and are
watching their CAUTI rates decline, while other life- and health-threatening
consequences of this practice are going unrecognized and unreported. The
CDCís own document, ì GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY
TRACT INFECTIONS 2009,î the basis for the CAUTI measure, specifically
addresses the SCI patient population. The document states that the
recommendation to remove a foley from SCI patients is a Category II
recommendation (p. 11), that the evidence to support the recommendation is
ìvery low qualityî (p. 34), and that Category II recommendations are ìnot
intended to be enforcedî (p. 32). The CAUTI measure in its current form
violates both the CDCís own recommended guidelines as well as the Clinical
Practice Guidelines for Neurogenic Bladder in Spinal Cord Injury. The measure
is driving practices which are clearly unsafe for SCI patients. Furthermore,
in SCI patients, the measure fails at its primary objective of measuring UTIs,
since the definition of UTI used is not valid in patients with chronic
indwelling catheters and impaired bladder sensation. The plight of SCI
patients represents an unintended adverse consequence of the CAUTI measure.
This issue has been raised by SCI subspecialists around the country and so far
has been falling on deaf ears. When conducting research, if I encounter an
unintended adverse consequence, I am held accountable by an Institutional
Review Board. I see no such safety mechanism in place for pay-for-performance
quality measures. I understand that the NQF does not have the authority to
modify or strike down the CAUTI measure. I am simply asking that you withhold
your endorsement until this real and very serious issue is adequately
addressed. Thank you for your consideration. Matt Davis, MD TIRR Memorial
Hermann Clinical Director of SCI Services (Submitted by: TIRR Memorial
Hermann)
- [Pre-workgroup meeting comment] Last March, a number of SCI
specialists from respected SCI centers across the country spoke out about this
measure. I have pasted these comments here, for your review:
=============================== Submitted by Stephen Burns, MD I agree with
the comments of Drs. Alander, Stampas, Francisco, Gershkoff, Berliner, and
Davis. Indwelling catheters are the most appropriate management option for
many patients with neurogenic bladder dysfunction secondary to spinal cord
injury. They have been recommended as an option in the Consortium for Spinal
Cord Medicine's clinical practice guideline on management of neurogenic
bladder. They are usually the best choice for patients who lack hand function
(or cognitive function) to reliably perform self intermittent catheterization.
There is no significant difference in the rate of symptomatic urinary tract
infections with indwelling catheters compared to other options in patients
with severe neurogenic bladder dysfunction. I have personally seen adverse
outcomes when Foley catheters are inappropriately discontinued in patients
with SCI. A patient currently hospitalized on my service had this occur when
he was at an outside hospital. He was returned to his nursing home without a
catheter and was required to have a urinal balanced between his thighs 24
hours per day, since he had no ability to control urination. When we admitted
him, he had a post-void residual of 400ml. We immediately replaced the Foley
catheter and educated the patient on the appropriateness of this for managing
his bladder. It is not reasonable to expect providers outside of tertiary care
centers to have the knowledge to select optimal management for this condition.
I fear that encouraging them to discontinue catheter management will have a
negative impact on quality of life in this population with no health benefit
gained. For these reasons, exclusion of SCI patients from the numerator of NQF
#0138 is therefore justified. =============================== Submitted by
Monica Verduzco-Gutierrez, MD The CAUTI Outcome measure is an excellent
quality guideline in the abled body population. I take care of patients with
catastrophic injuries (spinal cord injuries and severe acquired brain
injuries) and in this patient population with neurogenic bladder, the
discontinuation of a foley can be injurious or deadly. Some centers are not
aware or able to manage a patient that necessitates a intermittent
catheterization program. These patients can be harmed by hydronephrosis, renal
failure, bladder rupture when a necessary foley is removed. I urge you to
consider excluding SCI patients from these guidelines or excluding speciality
rehabilitation hospitals from this measure. Thank you.
=============================== Submitted by Dirk H. Alander, MD I work in at
a level one trauma center (ACS, Illinois, Missouri) serving both the inner
city and large rural areas. I would move to avoid the inclusion of the SCI
patient into the population of patients using catheters. The SCI patient
population has a diverse range of injury patterns, associated injuries, and
social issues that do not lend themselves to the average patient with a short
term need of a catheter. Lack of adequate care outside of the acute and
rehabilitation hospitals is a real concern when patients are unable to
complete serial catheterizations and have little or no resources for
assistance. There needs to be much stronger evidence to support one method or
another before penalizing physicians, institutions and patients for urinary
tract infections after catheter use in this challenging patient population.
=============================== Submitted by Carolyn Tillquist Regarding
measure #0138 As an Infectious Diseases specialist practicing at Craig
Hospital for sci and brain injury patients, I deal with bacteriuria and utis
on a daily basis. We have been working at Craig to study these measures in
this population so as to better understand what best practices may be.
Although studies are in progress, both here and at other centers across the
nation, guidelines appropriate for these unique patients have not been
established. We know that the guidelines used to address the acute care
population, that are represented in measure #0138, do not apply. Please
exclude this population from this measure; including them in the current
measure would be a disservice to the patients and to those of us who have
dedicated our expertise to providing them with the best care possible.
Thank-you, Carolyn Tillquist,MD
========================================================================
Submitted by William Carter, III,MD I am relatively new to exposure to
larger spinal cord injury/ trauma centers. Prior to working in one, I had no
concept of how to manage bladder function in SCI. Afterwards, as mentioned by
others, there is a struggle even without such a policy for their bladder
management to be appropriate. In addition to spinal cord injury, this measure
could also adversely impact other populations such as multiple sclerosis,
polytrauma, and others. When transitioning from an indwelling catheter we
almost invariably place patients on fluid restriction of 2L/day. Without this
restriction, to maintain a safe bladder volume in someone unable to void,
intermittent catheterization would need to be performed more frequently and
there is no study that shows that doing intermittent catheterization every 3
hours is safer than an indwelling catheter. Furthermore, in the acute care
setting almost invariably patients are continued on IV fluids, IV antibiotics,
etc, contributing to more rapid bladder filling. Catheters are placed for
multiple reasons and if there is good documentation for why it needs to be
continued (too high fluid intake, inability to self cath, reasons that bladder
accidents can't be risked such as sacral pressure sores (not unique to SCI
population), etc) that should ideally suffice. I can recall from my internal
medicine training that all patients with heart failure were supposed to be
discharged on an ACE-I or ARB as a quality standard. However, if documentation
suggesting a contraindication was provided, there was no penalty. What is the
best way to make exceptions to the rule?
========================================================================
Submitted by Argyrios Stampas, MD Urinary tract infections are an unfortunate
risk when maintaining an indwelling catheter. However, they are a necessity
for many patients with spinal cord injury or disease secondary to the risk of
high bladder pressures and the subsequent kidney damage that will ensue.
Ideally, these patients would have an intermittent catheter schedule, which
is well known to reduce the amount of UTIs. However, for many patients, they
cannot self cath, nor can their loved ones or caregivers. They must rely on
health care providers. That said, a skilled nursing facility is ill-equipped
to catheterize patients every 4 - 6 hours. Without the bladder being
intermittently decompressed, the pressures can elevate leading to kidney
damage and/or infection. Thus, facilities must continue to use indwelling
catheters and treat the potential UTI, versus the alternative of renal
failure, pyelonephritis, and other far worse morbidities that may occur,
compared to a UTI.
========================================================================
Submitted by Lance Goetz I concur with the cements from other spinal cord
injury (SCI) professionals. Indwelling catheters (urethral or suprapubic) are
sometimes the only viable option for persons with SCI and some other causes of
neurogenic bladder dysfunction. Removal of an indwelling catheter and
placement of an external catheter could put such persons at risk for a number
of serious complications, including vesicoueretral reflux due to outlet
obstruction, leading to stone disease and/or kidney damage. Further,
insistence on intermittent catheterization could cause persons with SCI to be
denied admission to certain facilities. I recommend allowing justification of
indwelling catheter use or making other accommodations for these persons.
========================================================================
Submitted by Gerard Francisco The use of indwelling catheters in SCI patients
may actually represent the safest alternative and highest quality of life
possible. This was specifically addressed in the 2009 CDC CAUTI guidelines
(Gould 2009): ìFor patients with spinal cord injury, very low-quality evidence
suggested a benefit of avoiding indwelling urinary catheters. This was based
on a decreased risk of UTI and bacteriuria in those without indwelling
catheters (including patients managed with spontaneous voiding, clean
intermittent catheterization [CIC], and external striated sphincterotomy with
condom catheter drainage), as well as a lower risk of urinary complications,
including hematuria, stones, and urethral injury (fistula, erosion,
stricture).î Patients with limited dexterity or high level injuries have to
rely on caregivers to provide intermittent catherization every 4 hour which
may not be feasible or a deterent to returning to work or other activities.
The evidence on suprapubic tubes is not clear as a infection prevention
strategy. Over the course of time, these patients become naturally colonized
with benign organism(s) that does not represent an acute infection and likely
should not be treated with antibiotics. This colonization most likely helps
protect the patient from developing a UTI from pathogenic organisms, such as
those that are antibiotic resistant. Thus, I have concerns that the current
CDC definition and implementation by NHSN for CAUTI is currently
overestimating events in the SCI population and does not adequately address
the symptomology seen in these patients. The 2009 CDC CAUTI guidelines (Gould,
et al. , 2009) specifically recognized that 100% of patients with an
indwelling catheter for more than 30 days will have bacteriuria; therefore, it
would be expected for all long term catheter patients to have a colony count
in the urine. The preventative efforts outlined in NQF #0138 are appropriate
for the care of any indwelling catheter and we fully support the implementing
securing catheters to the leg, keeping collection bags below the level of the
bladder, and utilizing aseptic techniques for insertions. Our organization is
implementing programs to address these issues. Our concern is that these
efforts will only minimally impact infections because of the unique issues for
SCI patients as adequate research and evidence is lacking. Thus, I strongly
recommend: 1) Excluding SCI patients from the numerator of NQF #0138; 2)
Developing a SCI specific definition of CAUTI to better reflect the events in
this population; 3) Developing a specific measure on CAUTI for this population
to further the knowledge and advance the preventative efforts that are likely
to have a clinical impact for patients (ex: use of leg bags, closed vs open
symptoms, managing colonizations). Thank you. ===============================
Submitted by Arthur Maurice Gershkoff, M.D. I am concerned that the outcome
measure related to catheter associated urinary tract infections may impact
adversely on the medical care received by persons with spinal cord injuries
and other severe physical disabilities. Such patients may be at risk for
urinary incontinence with complications(such as skin irritation and impeding
of the healing of skin ulcers) or for urinary retention. The policy threatens
financial repercussions to hospitals with above-average rates of
catheter-associated urinary tract infections (CAUTIs). In response, many
facilities are making efforts to remove indwelling catheters in all patients ñ
often including SCI patients and other patients with severe physical
disabilities. These facilities may not be adequately educated or equipped to
successfully implement an intermittent catheterization program, and I have
been told that some patients are simply having condom catheters placed --
putting them at risk for obstructive uropathy and renal failure. While the
incentive to move to intermittent catheterizaton is admirable for most
patients, some patients are completely unable to tolerate this because of pain
or anatomic problems. For some patients, a hypertonic bladder or lower motor
neuron type bladder with a flaccid urinary sphincter and incontinence between
catheterizations, may also not be tolerable. For those patients, intermittent
catheterization is not an option, and indwelling Foley catheterization may be
required. It is inevitable that patients with long term indwelling Foley
catheters will eventually become colonized, and that some of these will go on
to develop infection. It would be important in the evaluation of CAUTI's, to
make sure that hospitals that have a large number of severely physically
disabled patients, such as rehabilitation hospitals, not be compared with
other hospitals that do not admit such patients (and instead, refer them
elsewhere.) If all hospitals are lumped together, there needs to be some risk
adjustment based on the percentage of severely disabled persons who are
admitted. Thank you for your consideration of this. Sincerely yours, Arthur M.
Gershkoff M.D. =============================== Submitted by Jeff Berliner, DO
Dear NHSN- I am from Craig Hospital, a model Spinal Cord System that
specializes in the delivery of outstanding care to those with spinal cord and
traumatic brain injuries. CAUTI's are a formidable opponent in those living
with spinal cord injury that rely on Foley or Intermittent Catheterization
Programs to drain the bladder. In acute inpatient rehabilitation a team
approach is used to teach those with either full or poor hand function to use
an intermittent catheter program to drain the bladder every four hours. Even
with the best of hygiene, CAUTI's are unavoidable in many of these patients.
They are learning to manipulate a catheter into their meatus to drain their
bladder and are repeatedly performing this action with-in a hospital setting
every four hours to learn to become independent. We use gloves, sterile
catheters and iodine every time but still to no avail as many come down with
UTIís. If a person has poor hand function then a catheter must remain in the
bladder and a caregiver must learn how to change and flush the Foley. What I
am asking for is an exclusion for this unique patient population. They, their
bladders and their means of elimination of urine do not fit the mold or the
spirit of the very people that this new guideline is trying to protect. This
new law may force clinicians in spinal cord injury to prescribe unneeded
antiobiotic prophylaxis for all patients to protect against a CAUTI. I will
ask our research department to come with facts about the frequency of UTIís in
this patient population. Thank you for this consideration- Dr. Berliner
=============================== Submitted by Matthew Davis, MD While seeking
to achieve a highly reliable healthcare system, it is important not to
overlook the needs of special populations. One such population is that of
people with disabilities ñ which has been designated as a minority group with
protection under items of legislation such as the Americans with Disabilities
Act. This concern leads me to request a modification of NQF #0138 (NHSN
Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure) to
specifically exclude patients with spinal cord injuries (SCI). Specific
considerations include: 1) A thorough review of studies measuring UTI rates in
SCI patients with indwelling catheters versus other means of bladder
management fails to demonstrate a consistent, clear, and statistically
significant benefit to removing indwelling catheters. 2) In an effort to
reduce CAUTI rates, acute care hospitals have been removing indwelling
catheters while failing to implement an adequate alternative form of bladder
management. This puts SCI patients at risk for obstructive uropathy and renal
failure. In the 2009 CDC CAUTI guidelines, Gould, et al, admits ìFor patients
with spinal cord injury, very low-quality evidence suggested a benefit of
avoiding indwelling urinary catheters.î Likewise, the Clinical Practice
Guidelines prepared by the Consortium for Spinal Cord Medicine in 2006
acknowledge that the data regarding rates of UTI in SCI patients with
indwelling catheters versus those using intermittent catheterization is
conflicting. In other words, there is not a clear, unequivocal benefit from
removing indwelling catheters in terms of reducing UTI risk. What is clear and
unequivocal, however, is that patients with acute SCI require adequate bladder
drainage ñ either through indwelling catheterization or through intermittent
catheterization. Intermittent catheterization must be done according to a
strict protocol in order to avoid obstructive uropathy and risk for renal
failure. Unfortunately, acute care hospitals are not well-versed in
implementing this protocol due to a low incidence of SCI patients in most
hospital settings. In the past few weeks, presumably due to concerns about
CAUTI rates, TIRR rehabilitation hospital has seen increasing numbers of
patients referred from acute care hospitals who have been transitioned to
diapers or condom catheters, a practice which puts patients at risk for
obstructive uropathy and acute renal failure. Our specific requests are: 1)
Exclude SCI patients from the numerator of NQF #0138 2) Develop a SCI-specific
definition of UTI to better reflect events in this population. This should be
done with input from board-certified specialists in spinal cord
medicine.(Submitted by: various)
| (Program: Medicare Shared Savings Program; MUC ID: S0138)
|
- [Pre-workgroup meeting comment] Patients with spinal cord injuries
(SCI) often require the use of indwelling catheters to manage their neurogenic
bladders. In an effort to comply with the publicly-reported CAUTI outcome
measure, some physicians who are treating SCI patients with indwelling
catheters are removing these catheters in direct conflict with the only
published clinical practice guideline on the subject (Linsenmayer, T. (Ed.)
Bladder Management for Adults with Spinal Cord Injury: A clinical practice
guideline for health-care providers. (Washington, DC: Consortium of Spinal
Cord Medicine, 2006).). This action may compromise the short- and long-term
health of the patient with SCI in ways that are unknown to the treating
physician and perhaps even the patients themselves. On behalf of patients
with spinal cord injuries, I respectfully ask that patients with spinal cord
injuries be administratively excluded from this outcome measure. While the
CAUTI measure is clinically appropriate for the general population, the
guidelines for SCI population indicate that catheters are the preferred
bladder management solution for certain SCI patients. Unfortunately, these
guidelines are unfamiliar to many physicians who see only small numbers of
patients with SCI; in ignorance of the published CPG, many physicians are
removing catheters inappropriately to comply with the CAUTI measure. The
authors of the CPG have been trying to raise awareness of the guidelines
existence for many years among the general physician population. This has been
to small avail; the SCI population is simply too small for every physician to
read and recall guidelines specific to this group. The CAUTI measure, on the
other hand, is driving clinical decision-making because it is
publicly-reported and tied (albeit indirectly) to reputation and ultimately
reimbursement. Specialists in the field of spinal cord medicine have come to
the consensus that indwelling catheters are appropriate for a portion of the
SCI population; we respectfully request that patients with spinal cord
injuries be administratively excluded from the CAUTI reporting guidelines as
the removal of indwelling catheters in this population follows a treatment
algorithm that differs from the general public and which is unknown to many
physicians who only treat the occasional patient with spinal cord injury.
(Submitted by: Quality of Life Advisors, Inc.)
- [Pre-workgroup meeting comment] The following is from a letter from
the president of the American Spinal Injury Association (ASIA), a professional
organization dedicated to the care of patients with Spinal Cord Injury (SCI).
This letter was approved by ASIAís board of directors prior to its release. I
have emailed a scanned copy of this letter, with letterhead and signature, to
Robert Saunders, senior director of the NQF: Drs. Frieden, Pollock, Gould,
and Pines: As care providers of patients with Spinal Cord Injuries (SCI), we
are seeing an alarming increase in the number of patients whose bladders are
managed in an unsafe manner following the transition last October toward ìPay
for Performanceî status of the National Healthcare Safety Network (NHSN)
Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure.
Hospitals' emphasis on removal of indwelling catheters is not surprising,
given the financial penalties involved and the public reporting of CAUTI rates
as an indicator of "quality healthcare." Unfortunately, most non-specialty
hospital settings are not adequately experienced in implementing an
intermittent catheterization (IC) program. Many physicians and nurses, in
fact, are not even aware of the need to perform IC in SCI patients. The
Consortium for Spinal Cord Medicine's Clinical Practice Guidelines for Bladder
Management for Adults with Spinal Cord Injury, one of the most definitive and
widely-accepted treatises on the subject, clearly indicate that indwelling
catheterization is preferable to poorly-implemented IC. While many of us
prefer suprapubic catheters to Foley catheters in the long term, this option
is simply not available in the first several weeks following SCI.
Additionally, the CAUTI measure focuses exclusively on UTI risk as the sole
consideration in selecting the method of bladder management in SCI. We believe
that indwelling catheterization remains a valuable option in a substantial
portion of SCI patients for a variety of reasons. Once again, these reasons
are outlined in the Clinical Practice Guidelines, which were assembled through
a rigorous review of the literature and of expert consensus by a team of
Neuro-Urologists, Certified Rehabilitation Nurses, and Physiatrists who
sub-specialize in SCI. Facilities which judiciously use indwelling catheters
are by no means providing substandard care. The public reporting of CAUTIs as
an indicator of "quality healthcare" in SCI patients adds insult to injury. It
risks leading patients and their families to facilities poorly equipped to
handle this catastrophic injury. Facilities without the insight to use
indwelling catheters judiciously will appear to be providing better care than
SCI specialty centers. Inadequately-implemented (or nonexistent) IC puts SCI
patients at risk for upper urinary tract deterioration, autonomic dysreflexia
(with resulting hypertensive emergency), and UTI related to urinary retention.
By indiscriminately removing Foley catheters, non-specialty hospitals can see
their CAUTI rates decline, while these life-threatening adverse consequences
are going unmeasured and unrecognized. One solution suggested by the CDC has
been that SCI physicians educate the medical community as a whole about how to
properly implement IC and how to identify which patients are appropriate for
continued foley use. Unfortunately, these are complicated decisions which are
usually made SCI sub-specialists working in tertiary care centers with
specialty-trained nurses. Most acute care nursing units see very few SCI
patients in a year. The operational feasibility of such a solution seems very
small, especially given the financial disincentives in place. The financial
penalty and public reporting of the CAUTI measure are driving practices which
deviate from acceptable medical care for patients with SCI. Accordingly, we
are requesting that CDC-NHSN add UTIs in SCI patients to the list of UTIs that
are excluded from a hospitalís CAUTI count, in a similar manner that UTIs
related to suprapubic catheters are excluded. Sincerely, Michael H. Haak, MD
ASIA President(Submitted by: American Spinal Injury Association
(ASIA))
- [Pre-workgroup meeting comment] I am comment on behalf of myself
and not representing Select Medical or Kessler Institute or PVA. I am the
Director of Urology at Kessler Institute for Rehabilitation and have been
working with SCI patients for the past 25 years. I am one of 2 urologists in
the country who is double boarded in Urology, Physical Medicine and
Rehabilitation as well as Spinal Cord Injury Medicine. I am the chairman of
the PVA SCI Consortium Guidelines on Bladder Management in Those With SCI. I
am also one of the committee members and authors of the recently published
International Data Set on UTIís in Those with SCI. While I think the
guidelines have a lot of merit in not leaving in a catheter in able bodied
individuals in an acute care hospital setting, I am very concerned with the
current CAUTI guidelines as they apply to those with indwelling catheters and
have an SCI. The financial penalty and public reporting of the CAUTI measure
encouraging the practice of removing a catheter in certain SCI individuals
which deviate from acceptable medical care for patients with SCI. Part of the
problem is that the definition of a UTI is very different in individuals with
SCI and neurogenic bladders compared to those who do not have a SCI.
Increased bacteria in the urine is considered to be the definition of a UTI in
non SCI, able bodied individuals. However, those with SCI WITH and WITHOUT an
indwelling catheter are routinely are colonized with bacteria in their
bladder. There is strong consensus that a person with a SCI should not be
considered to have an UTI just because of having bacteria in the bladder.
While there can be exceptions, 3 criteria need to be met to meet the
definition of a UTI in an individual with a SCI. These are; 1. bacteria in the
bladder (which almost all SCI individuals have), 2. increased WBCís in the
urine (that can occur from passing a catheter during intermittent
catheterization or an indwelling catheter) and very important, 3. the NEW
onset of symptoms. Our SCI bladder management consortium guidelines
(Linsenmeyer, T. (Ed.) Bladder Management for Adults with Spinal Cord Injury:
A clinical practice guideline for health-care providers. (Washington, DC:
Consortium of Spinal Cord Medicine, 2006).) specifically state that an
indwelling catheter should be considered in individuals who have poor hand
function and unable to catheterize themselves or do not have a willing
caregiver. This is because it is essential that the bladder is drained in a
timely manner. If a person is unable to catheterize themselves and the bladder
gets overdistended they can get a UTI or sepsis. In addition, if a person has
a SCI at T6 level or above (which includes those with poor hand function),
failure to drain the bladder can lead to a sudden severe potentially life
threatening rise in BP called autonomic dysreflexia. An indwelling catheter
is the safest way to keep this from happening. Also it is during the inpatient
setting that a person with a SCI and their family learn how to take care of
an indwelling catheter. If they are not taught how to manage an indwelling
catheter, the result is frequently to send a person home on intermittent
catheterization. The ìcaregiverî in most situations is a family member, so
that a wife or husband, mother or father has to suddenly take on the role of a
ìcaregiverî rather than a spouse, or a mother is now having to catheterize her
21 year old son around the clock. Intermittent catheterization requires
getting undressed so that a catheter can be passed down a persons urethra
every 4 to 6 hours and requires the trained person be available at all times
in case their bladder fills up quickly and the person with the SCI starts to
get autonomic dysreflexia. So now, as a result of having to perform
intermittent catheterization instead of having an indwelling catheter, both
the person with the SCI and person performing intermittent catheterization
need to be with each other at all times and causing both lose their
independence and have a significant decrease in their quality of life. This
is not the case with an indwelling catheter where there is a drainage bag
attached under the pants of the lower leg and can easily be reached and
drained by an untrained person by just twisting a small valve at the bottom of
the drainage bag. The other scenario is that a person with a long term SCI
and indwelling catheter is admitted to an acute care hospital for some medical
problem. The bladder becomes smaller with an indwelling catheter, and if it
were removed by a hospital staff that was not familiar with SCI in order to
decrease the risk of a financial penalty and public reporting of a CAUTI, the
SCI person would most certainly develop autonomic dysreflexia because of rapid
overdistention of their small bladder capacity. It should also be noted that
evaluation and management of acute autonomic dysreflexia is something that
most acute care hospital staff are not use to dealing with. In summary,
indwelling catheters for some SCI individuals is not only medically safer, but
allows a much better quality of life. The definitions of a UTI are also
different in those with an SCI. Under the definition of a UTI for able bodied
individual, almost all of our SCI patients who are colonized with bacteria,
with and without an indwelling catheter would be considered to have a UTI.
Those with an indwelling catheter would be classified as having a CAUTI.
Unfortunately, the financial penalty and public reporting of the CAUTI measure
are driving practices of removing catheters in those who cannot catheterize
themselves, which deviate from acceptable medical care for patients with SCI.
I therefore request that CDC-NHSN add UTIs in SCI patients to the list of
UTIs that are excluded from a hospitalís CAUTI count, in a similar manner that
UTIs related to suprapubic catheters are excluded. Respectfully submitted, Dr.
Todd Linsenmeyer, MD (Submitted by: Kessler Institute)
- [Pre-workgroup meeting comment] I have made a few minor editorial
changes from my comments recently submitted. Please use the following comment
instead. Thank you. T.L. I am commenting on behalf of myself and not
representing Select Medical or Kessler Institute or PVA. I am the Director of
Urology at Kessler Institute for Rehabilitation and have been working with SCI
patients for the past 25 years. I am one of 2 urologists in the country who is
double boarded in Urology, Physical Medicine and Rehabilitation as well as
Spinal Cord Injury Medicine. I am the chairman of the PVA SCI Consortium
Guidelines on Bladder Management in Those With SCI. I am also one of the
committee members and authors of the recently published International Data Set
on UTIís in Those with SCI. While I think the guidelines have a lot of merit
in not leaving in a catheter in able bodied individuals in an acute care
hospital setting, I am very concerned with the current CAUTI guidelines as
they apply to those with indwelling catheters and have an SCI. The financial
penalty and public reporting of the CAUTI measure are encouraging the practice
of removing catheters in certain SCI individuals, which deviate from accepted
medical care for patients with SCI. Part of the problem is that the
definition of a UTI is very different in individuals with SCI and neurogenic
bladders compared to those who do not have a SCI. Increased bacteria in the
urine is considered to be the definition of a UTI in non SCI, able bodied
individuals. However, those with SCI WITH and WITHOUT an indwelling catheter
are routinely are colonized with bacteria in their bladder. There is strong
consensus that a person with a SCI should not be considered to have an UTI
just because of having bacteria in the bladder. While there can be
exceptions, 3 criteria need to be met to meet the definition of a UTI in an
individual with a SCI. These are; 1. bacteria in the bladder (which almost all
SCI individuals have), 2. increased WBCís in the urine (that can occur from
passing a catheter during intermittent catheterization or an indwelling
catheter) and very important, 3. the NEW onset of symptoms. Our SCI bladder
management consortium guidelines (Linsenmeyer, T. (Ed.) Bladder Management
for Adults with Spinal Cord Injury: A clinical practice guideline for
health-care providers. (Washington, DC: Consortium of Spinal Cord Medicine,
2006) specifically state that an indwelling catheter should be considered in
individuals who have poor hand function and unable to catheterize themselves
or do not have a willing caregiver. This is because it is essential that the
bladder is drained in a timely manner. If a person is unable to catheterize
themselves and the bladder gets over distended they can get a UTI or sepsis.
In addition, if a person has a SCI at T6 level or above (which includes those
with poor hand function), failure to drain the bladder can lead to a sudden
severe potentially life threatening rise in BP called autonomic dysreflexia.
An indwelling catheter is the safest way to keep this from happening. Also it
is during the inpatient setting that a person with a SCI and their family
learns how to take care of an indwelling catheter. If they are not taught how
to manage an indwelling catheter, the result is frequently to send a person
home on intermittent catheterization. The ìcaregiverî in most situations is a
family member, so that a wife or husband, mother or father has to suddenly
take on the role of a ìcaregiverî rather than a spouse, or a mother now has to
catheterize her 21 year old son around the clock. Intermittent
catheterization requires getting undressed so that a catheter can be passed
down a personís urethra every 4 to 6 hours and requires the trained person be
available at all times in case their bladder fills up quickly and the person
with the SCI starts to get autonomic dysreflexia. So now, as a result of
having to perform intermittent catheterization instead of having an indwelling
catheter, both the person with the SCI and person performing intermittent
catheterization need to be with each other at all times and causing both lose
their independence and have a significant decrease in their quality of life.
This is not the case with an indwelling catheter where there is a drainage
bag attached under the pants of the lower part of the leg and can easily be
reached and drained even by an untrained person by just twisting a small
valve at the bottom of the drainage bag. Another scenario is that a person
with a long term SCI and indwelling catheter is admitted to an acute care
hospital for a non UTI medical problem. The bladder becomes smaller with an
indwelling catheter, and if it were removed by a hospital staff that was not
familiar with SCI, in order to decrease the risk of a financial penalty and
public reporting of a CAUTI, the SCI person would most certainly develop
autonomic dysreflexia due to rapid over distention of their small bladder
capacity. It should also be noted that evaluation and management of acute
autonomic dysreflexia is something that most acute care hospital staff are not
use to dealing with. In summary, indwelling catheters for some SCI
individuals are not only medically safer, but allow a much better quality of
life. Under the definition of a UTI for able bodied individual, almost all of
our SCI patients who are colonized with bacteria, with and without an
indwelling catheter would be considered to have a UTI. Those with an
indwelling catheter would be classified as having a CAUTI. Unfortunately, the
financial penalty and public reporting of the CAUTI measure are driving
practices of removing catheters in those with SCI who cannot catheterize
themselves, which as discussed above deviate from accepted medical care for
patients with SCI. I therefore request that CDC-NHSN add UTIs in SCI patients
to the list of UTIs that are excluded from a hospitalís CAUTI count, in a
similar manner that UTIs related to suprapubic catheters are excluded.
Respectfully submitted, Dr. Todd Linsenmeyer, MD (Submitted by: Kessler
Institute)
- [Pre-workgroup meeting comment] 12/5/14 Members of the MAP:
Hopefully you have seen and read the letter from the American Spinal Injury
Association (ASIA). Last March, a number of SCI specialists from respected SCI
centers across the country spoke out about this measure on the NQF website,
and I will include these comments in a separate post. They should also be
available to you in your records. Concerns about the use of so-called
ìpay-for-performanceî quality standards in healthcare have been raised by
groups such as the American Medical Association, American Academy of Family
Physicians, American College of Physicians, American Geriatrics Society, and
American Academy of Neurology. Concerns often center around the care of
medically complex patients who do not easily fit into simple treatment
paradigms. The plight of SCI patients and the CAUTI measure brings these
issues into clear focus. In patients with SCI, bladder overdistension is a
leading cause of Autonomic Dysreflexia (AD), a sympathetic storming event that
drives patientsí blood pressures into the Hypertensive Emergency range and can
produce stroke, seizures, and death. Following the transition toward
pay-for-performance for the CAUTI measure that occurred last October, SCI
specialists across the country have been seeing unprecedented rates of
inappropriate catheter removal and failure to implement adequate bladder
drainage in SCI patients. These patients are at risk for AD, UTI related to
urinary retention, hydronephrosis and renal failure. Most hospitals have
limited experience with SCI and are unprepared to manage SCI neurogenic
bladder without a foley. These hospitals are removing the foleys and are
watching their CAUTI rates decline, while other life- and health-threatening
consequences of this practice are going unrecognized and unreported. The
CDCís own document, ì GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY
TRACT INFECTIONS 2009,î the basis for the CAUTI measure, specifically
addresses the SCI patient population. The document states that the
recommendation to remove a foley from SCI patients is a Category II
recommendation (p. 11), that the evidence to support the recommendation is
ìvery low qualityî (p. 34), and that Category II recommendations are ìnot
intended to be enforcedî (p. 32). The CAUTI measure in its current form
violates both the CDCís own recommended guidelines as well as the Clinical
Practice Guidelines for Neurogenic Bladder in Spinal Cord Injury. The measure
is driving practices which are clearly unsafe for SCI patients. Furthermore,
in SCI patients, the measure fails at its primary objective of measuring UTIs,
since the definition of UTI used is not valid in patients with chronic
indwelling catheters and impaired bladder sensation. The plight of SCI
patients represents an unintended adverse consequence of the CAUTI measure.
This issue has been raised by SCI subspecialists around the country and so far
has been falling on deaf ears. When conducting research, if I encounter an
unintended adverse consequence, I am held accountable by an Institutional
Review Board. I see no such safety mechanism in place for pay-for-performance
quality measures. I understand that the NQF does not have the authority to
modify or strike down the CAUTI measure. I am simply asking that you withhold
your endorsement until this real and very serious issue is adequately
addressed. Thank you for your consideration. Matt Davis, MD TIRR Memorial
Hermann Clinical Director of SCI Services (Submitted by: TIRR Memorial
Hermann)
- [Pre-workgroup meeting comment] Last March, a number of SCI
specialists from respected SCI centers across the country spoke out about this
measure. I have pasted these comments here, for your review:
=============================== Submitted by Stephen Burns, MD I agree with
the comments of Drs. Alander, Stampas, Francisco, Gershkoff, Berliner, and
Davis. Indwelling catheters are the most appropriate management option for
many patients with neurogenic bladder dysfunction secondary to spinal cord
injury. They have been recommended as an option in the Consortium for Spinal
Cord Medicine's clinical practice guideline on management of neurogenic
bladder. They are usually the best choice for patients who lack hand function
(or cognitive function) to reliably perform self intermittent catheterization.
There is no significant difference in the rate of symptomatic urinary tract
infections with indwelling catheters compared to other options in patients
with severe neurogenic bladder dysfunction. I have personally seen adverse
outcomes when Foley catheters are inappropriately discontinued in patients
with SCI. A patient currently hospitalized on my service had this occur when
he was at an outside hospital. He was returned to his nursing home without a
catheter and was required to have a urinal balanced between his thighs 24
hours per day, since he had no ability to control urination. When we admitted
him, he had a post-void residual of 400ml. We immediately replaced the Foley
catheter and educated the patient on the appropriateness of this for managing
his bladder. It is not reasonable to expect providers outside of tertiary care
centers to have the knowledge to select optimal management for this condition.
I fear that encouraging them to discontinue catheter management will have a
negative impact on quality of life in this population with no health benefit
gained. For these reasons, exclusion of SCI patients from the numerator of NQF
#0138 is therefore justified. =============================== Submitted by
Monica Verduzco-Gutierrez, MD The CAUTI Outcome measure is an excellent
quality guideline in the abled body population. I take care of patients with
catastrophic injuries (spinal cord injuries and severe acquired brain
injuries) and in this patient population with neurogenic bladder, the
discontinuation of a foley can be injurious or deadly. Some centers are not
aware or able to manage a patient that necessitates a intermittent
catheterization program. These patients can be harmed by hydronephrosis, renal
failure, bladder rupture when a necessary foley is removed. I urge you to
consider excluding SCI patients from these guidelines or excluding speciality
rehabilitation hospitals from this measure. Thank you.
=============================== Submitted by Dirk H. Alander, MD I work in at
a level one trauma center (ACS, Illinois, Missouri) serving both the inner
city and large rural areas. I would move to avoid the inclusion of the SCI
patient into the population of patients using catheters. The SCI patient
population has a diverse range of injury patterns, associated injuries, and
social issues that do not lend themselves to the average patient with a short
term need of a catheter. Lack of adequate care outside of the acute and
rehabilitation hospitals is a real concern when patients are unable to
complete serial catheterizations and have little or no resources for
assistance. There needs to be much stronger evidence to support one method or
another before penalizing physicians, institutions and patients for urinary
tract infections after catheter use in this challenging patient population.
=============================== Submitted by Carolyn Tillquist Regarding
measure #0138 As an Infectious Diseases specialist practicing at Craig
Hospital for sci and brain injury patients, I deal with bacteriuria and utis
on a daily basis. We have been working at Craig to study these measures in
this population so as to better understand what best practices may be.
Although studies are in progress, both here and at other centers across the
nation, guidelines appropriate for these unique patients have not been
established. We know that the guidelines used to address the acute care
population, that are represented in measure #0138, do not apply. Please
exclude this population from this measure; including them in the current
measure would be a disservice to the patients and to those of us who have
dedicated our expertise to providing them with the best care possible.
Thank-you, Carolyn Tillquist,MD
========================================================================
Submitted by William Carter, III,MD I am relatively new to exposure to
larger spinal cord injury/ trauma centers. Prior to working in one, I had no
concept of how to manage bladder function in SCI. Afterwards, as mentioned by
others, there is a struggle even without such a policy for their bladder
management to be appropriate. In addition to spinal cord injury, this measure
could also adversely impact other populations such as multiple sclerosis,
polytrauma, and others. When transitioning from an indwelling catheter we
almost invariably place patients on fluid restriction of 2L/day. Without this
restriction, to maintain a safe bladder volume in someone unable to void,
intermittent catheterization would need to be performed more frequently and
there is no study that shows that doing intermittent catheterization every 3
hours is safer than an indwelling catheter. Furthermore, in the acute care
setting almost invariably patients are continued on IV fluids, IV antibiotics,
etc, contributing to more rapid bladder filling. Catheters are placed for
multiple reasons and if there is good documentation for why it needs to be
continued (too high fluid intake, inability to self cath, reasons that bladder
accidents can't be risked such as sacral pressure sores (not unique to SCI
population), etc) that should ideally suffice. I can recall from my internal
medicine training that all patients with heart failure were supposed to be
discharged on an ACE-I or ARB as a quality standard. However, if documentation
suggesting a contraindication was provided, there was no penalty. What is the
best way to make exceptions to the rule?
========================================================================
Submitted by Argyrios Stampas, MD Urinary tract infections are an unfortunate
risk when maintaining an indwelling catheter. However, they are a necessity
for many patients with spinal cord injury or disease secondary to the risk of
high bladder pressures and the subsequent kidney damage that will ensue.
Ideally, these patients would have an intermittent catheter schedule, which
is well known to reduce the amount of UTIs. However, for many patients, they
cannot self cath, nor can their loved ones or caregivers. They must rely on
health care providers. That said, a skilled nursing facility is ill-equipped
to catheterize patients every 4 - 6 hours. Without the bladder being
intermittently decompressed, the pressures can elevate leading to kidney
damage and/or infection. Thus, facilities must continue to use indwelling
catheters and treat the potential UTI, versus the alternative of renal
failure, pyelonephritis, and other far worse morbidities that may occur,
compared to a UTI.
========================================================================
Submitted by Lance Goetz I concur with the cements from other spinal cord
injury (SCI) professionals. Indwelling catheters (urethral or suprapubic) are
sometimes the only viable option for persons with SCI and some other causes of
neurogenic bladder dysfunction. Removal of an indwelling catheter and
placement of an external catheter could put such persons at risk for a number
of serious complications, including vesicoueretral reflux due to outlet
obstruction, leading to stone disease and/or kidney damage. Further,
insistence on intermittent catheterization could cause persons with SCI to be
denied admission to certain facilities. I recommend allowing justification of
indwelling catheter use or making other accommodations for these persons.
========================================================================
Submitted by Gerard Francisco The use of indwelling catheters in SCI patients
may actually represent the safest alternative and highest quality of life
possible. This was specifically addressed in the 2009 CDC CAUTI guidelines
(Gould 2009): ìFor patients with spinal cord injury, very low-quality evidence
suggested a benefit of avoiding indwelling urinary catheters. This was based
on a decreased risk of UTI and bacteriuria in those without indwelling
catheters (including patients managed with spontaneous voiding, clean
intermittent catheterization [CIC], and external striated sphincterotomy with
condom catheter drainage), as well as a lower risk of urinary complications,
including hematuria, stones, and urethral injury (fistula, erosion,
stricture).î Patients with limited dexterity or high level injuries have to
rely on caregivers to provide intermittent catherization every 4 hour which
may not be feasible or a deterent to returning to work or other activities.
The evidence on suprapubic tubes is not clear as a infection prevention
strategy. Over the course of time, these patients become naturally colonized
with benign organism(s) that does not represent an acute infection and likely
should not be treated with antibiotics. This colonization most likely helps
protect the patient from developing a UTI from pathogenic organisms, such as
those that are antibiotic resistant. Thus, I have concerns that the current
CDC definition and implementation by NHSN for CAUTI is currently
overestimating events in the SCI population and does not adequately address
the symptomology seen in these patients. The 2009 CDC CAUTI guidelines (Gould,
et al. , 2009) specifically recognized that 100% of patients with an
indwelling catheter for more than 30 days will have bacteriuria; therefore, it
would be expected for all long term catheter patients to have a colony count
in the urine. The preventative efforts outlined in NQF #0138 are appropriate
for the care of any indwelling catheter and we fully support the implementing
securing catheters to the leg, keeping collection bags below the level of the
bladder, and utilizing aseptic techniques for insertions. Our organization is
implementing programs to address these issues. Our concern is that these
efforts will only minimally impact infections because of the unique issues for
SCI patients as adequate research and evidence is lacking. Thus, I strongly
recommend: 1) Excluding SCI patients from the numerator of NQF #0138; 2)
Developing a SCI specific definition of CAUTI to better reflect the events in
this population; 3) Developing a specific measure on CAUTI for this population
to further the knowledge and advance the preventative efforts that are likely
to have a clinical impact for patients (ex: use of leg bags, closed vs open
symptoms, managing colonizations). Thank you. ===============================
Submitted by Arthur Maurice Gershkoff, M.D. I am concerned that the outcome
measure related to catheter associated urinary tract infections may impact
adversely on the medical care received by persons with spinal cord injuries
and other severe physical disabilities. Such patients may be at risk for
urinary incontinence with complications(such as skin irritation and impeding
of the healing of skin ulcers) or for urinary retention. The policy threatens
financial repercussions to hospitals with above-average rates of
catheter-associated urinary tract infections (CAUTIs). In response, many
facilities are making efforts to remove indwelling catheters in all patients ñ
often including SCI patients and other patients with severe physical
disabilities. These facilities may not be adequately educated or equipped to
successfully implement an intermittent catheterization program, and I have
been told that some patients are simply having condom catheters placed --
putting them at risk for obstructive uropathy and renal failure. While the
incentive to move to intermittent catheterizaton is admirable for most
patients, some patients are completely unable to tolerate this because of pain
or anatomic problems. For some patients, a hypertonic bladder or lower motor
neuron type bladder with a flaccid urinary sphincter and incontinence between
catheterizations, may also not be tolerable. For those patients, intermittent
catheterization is not an option, and indwelling Foley catheterization may be
required. It is inevitable that patients with long term indwelling Foley
catheters will eventually become colonized, and that some of these will go on
to develop infection. It would be important in the evaluation of CAUTI's, to
make sure that hospitals that have a large number of severely physically
disabled patients, such as rehabilitation hospitals, not be compared with
other hospitals that do not admit such patients (and instead, refer them
elsewhere.) If all hospitals are lumped together, there needs to be some risk
adjustment based on the percentage of severely disabled persons who are
admitted. Thank you for your consideration of this. Sincerely yours, Arthur M.
Gershkoff M.D. =============================== Submitted by Jeff Berliner, DO
Dear NHSN- I am from Craig Hospital, a model Spinal Cord System that
specializes in the delivery of outstanding care to those with spinal cord and
traumatic brain injuries. CAUTI's are a formidable opponent in those living
with spinal cord injury that rely on Foley or Intermittent Catheterization
Programs to drain the bladder. In acute inpatient rehabilitation a team
approach is used to teach those with either full or poor hand function to use
an intermittent catheter program to drain the bladder every four hours. Even
with the best of hygiene, CAUTI's are unavoidable in many of these patients.
They are learning to manipulate a catheter into their meatus to drain their
bladder and are repeatedly performing this action with-in a hospital setting
every four hours to learn to become independent. We use gloves, sterile
catheters and iodine every time but still to no avail as many come down with
UTIís. If a person has poor hand function then a catheter must remain in the
bladder and a caregiver must learn how to change and flush the Foley. What I
am asking for is an exclusion for this unique patient population. They, their
bladders and their means of elimination of urine do not fit the mold or the
spirit of the very people that this new guideline is trying to protect. This
new law may force clinicians in spinal cord injury to prescribe unneeded
antiobiotic prophylaxis for all patients to protect against a CAUTI. I will
ask our research department to come with facts about the frequency of UTIís in
this patient population. Thank you for this consideration- Dr. Berliner
=============================== Submitted by Matthew Davis, MD While seeking
to achieve a highly reliable healthcare system, it is important not to
overlook the needs of special populations. One such population is that of
people with disabilities ñ which has been designated as a minority group with
protection under items of legislation such as the Americans with Disabilities
Act. This concern leads me to request a modification of NQF #0138 (NHSN
Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure) to
specifically exclude patients with spinal cord injuries (SCI). Specific
considerations include: 1) A thorough review of studies measuring UTI rates in
SCI patients with indwelling catheters versus other means of bladder
management fails to demonstrate a consistent, clear, and statistically
significant benefit to removing indwelling catheters. 2) In an effort to
reduce CAUTI rates, acute care hospitals have been removing indwelling
catheters while failing to implement an adequate alternative form of bladder
management. This puts SCI patients at risk for obstructive uropathy and renal
failure. In the 2009 CDC CAUTI guidelines, Gould, et al, admits ìFor patients
with spinal cord injury, very low-quality evidence suggested a benefit of
avoiding indwelling urinary catheters.î Likewise, the Clinical Practice
Guidelines prepared by the Consortium for Spinal Cord Medicine in 2006
acknowledge that the data regarding rates of UTI in SCI patients with
indwelling catheters versus those using intermittent catheterization is
conflicting. In other words, there is not a clear, unequivocal benefit from
removing indwelling catheters in terms of reducing UTI risk. What is clear and
unequivocal, however, is that patients with acute SCI require adequate bladder
drainage ñ either through indwelling catheterization or through intermittent
catheterization. Intermittent catheterization must be done according to a
strict protocol in order to avoid obstructive uropathy and risk for renal
failure. Unfortunately, acute care hospitals are not well-versed in
implementing this protocol due to a low incidence of SCI patients in most
hospital settings. In the past few weeks, presumably due to concerns about
CAUTI rates, TIRR rehabilitation hospital has seen increasing numbers of
patients referred from acute care hospitals who have been transitioned to
diapers or condom catheters, a practice which puts patients at risk for
obstructive uropathy and acute renal failure. Our specific requests are: 1)
Exclude SCI patients from the numerator of NQF #0138 2) Develop a SCI-specific
definition of UTI to better reflect events in this population. This should be
done with input from board-certified specialists in spinal cord
medicine.(Submitted by: various)
| (Program: Hospital-Acquired Condition (HAC)
Reduction Program ; MUC ID: S0139) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
| (Program: Hospital Value-Based Purchasing
Program; MUC ID: S0139) |
- The Consumer-Purchaser Alliance is concerned about the recommended
condition that these measures be used in the Hospital Value-Based Purchasing
Program (HVBP)only following public reporting. We believe this condition
would only be appropriate as statutorily mandated. Moreover, we fully support
the swift and simultaneous implementation of these measures within the HVBP
program and across all other programs in which they are already in use. We
believe immediate implementation of the most recent version of the measure
will support continued alignment of measures across federal programs and
ensure that the most scientifically rigorous and up-to-date versions of
NQF-endorsed measures are implemented in a timely fashion. Additionally, we
would like to draw attention to results from the FY 2015 HVBP program, which
indicate that over 50% of eligible hospitals received payment incentives
through this program based on demonstrated performance. This figure
represents a rise in hospitals benefiting from the program from the year
prior, and we caution MAP against recommending an approach to measure updates
that might result in slowed progress or steps backwards from the success
achieved to date in improving health care quality.(Submitted by:
Consumer-Purchaser Alliance)
| (Program: Inpatient Quality Reporting Program ; MUC ID:
S0139) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
| (Program:
Medicare Shared Savings Program; MUC ID: S2510) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- The Service Employees International Union (SEIU) appreciates the
opportunity to submit comments on the Hospital Measures Application
Partnership (MAP) Measures under Consideration. Given the multitude of roles
of our members in the health care system, we have a compelling interest in the
Hospital and PAC/LTC MAP, and we welcome the opportunity to add our unique
voice to this discussion. SEIU recognizes the importance of reducing
hospital readmissions from skilled nursing facilities, and is pleased that CMS
is taking steps to implement a skilled nursing facility value-based purchasing
program. Given that NQF endorsed two different SNF all-cause 30 day post
discharge readmission quality measures (NQF 2375 and 2510) as part of the
All-Cause admissions and readmissions project, which use different datasets
(MDS vs claims data) and contain different exclusions and risk adjustment
factors, we encourage CMS, NQF, and the MAP to explore whether there
adjustments that can be made to the claims data or MDS data so the best
possible measure can be developed. SEIU does agree that planned readmissions
should be excluded. Additionally, it is important that there is frequent
review of unintended consequences, such as patients not having access to
hospitalizations when needed due to fear of a SNF receiving a penalty.
Additionally, there should be an exploration on whether SDS risk-adjustment
for this measure is appropriate during the NQF trial period. SEIU recommends
that MAP should change their position to conditional support. (Submitted by:
SEIU)
- American Health Care Association (AHCA) is submitting comments on MAP
measure s2510 Skilled Nursing Facility All-Cause 30 Day Post Discharge
Readmission Measure. AHCA has concerns with the use of this measure for
several reasons. First, this measure only captures readmission rates for
Medicare fee for service (FFS) beneficiaries. For approximately 9,800 of the
15,000+ skilled nursing facilities (SNFs) in the country, Medicare FFS
admissions comprise less or equal to 70 percent of their total admissions;
with nearly 50% having less than or equal to 50 percent of their admissions as
Medicare FFS (see Table 1). In general, when data is not available on 30% or
more of a population; the measures may not be representative. So a FFS
Medicare only measure has missing data for all non-Medicare FFS admissions
which this table shows is very prevalent in SNFs. Thus, measure s2510 can be
very misleading when evaluating the readmission rate for a SNF. Second, this
measure captures readmissions that occur both during and after SNF discharge.
The SNF value based purchasing program is designed to address readmissions
during the SNF stay and this measure and this measure is not consistent with
this. Third, this measure does not capture hospital admissions classified as
observation status since it utilizes Medicare Part A claims. These admissions
contribute both to the morbidity of patients and Medicare costs and should be
included. Fourth, this measure uses a predicted actual for the numerator
which adjusts the actual readmission rate based on bed size. This has the
effect of muting differences in rates for smaller SNFs. It also makes
interpreting this measure much more difficult by providers, public and payors.
Fifth, this measure can only risk adjust for diagnoses and demographic
characteristics available on claims. However, diagnoses alone do not capture
illness severity, functional status and clinical symptoms which are strong
predictors of hospital readmissions. We recommend that MAP look at NQF
endorsed measure 2375 PointRight Æ Pro 30ô before taking a position on measure
s2510. NQF measure 2375 is a MDS based measure that captures all patients
regardless of payor type and observation admissions. Additionally, it risk
adjusts for functional and clinical symptoms as well as demographics and
diagnoses.
|Cumulative |Cumulative %of Admissions that are
Medicare| Number of Facilities| %of Facilities Exactly 0%
| 24 | 0% =10%
|152 | 1% =20%
|636 |
5% =30% |1,717
| 15% =40% |3,548
| 30% =50% |5,831
| 50% =60%
|8,058 | 69% =70%
|9,843 | 84% =80%
|10,991 | 94% =90%
|11,536 | 98% =100%
|11,726 | 100% (Submitted
by: American Health Care Association )
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
| (Program:
Skilled Nursing Facilities Value-Based Purchasing; MUC ID: S2510)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- Would addition of the measure add value to the program measure set? Maybe
What is the measureís potential to improve patient outcomes? AGS notes that
while this may be a useful differentiator of quality, further understanding of
30 day readmissions might be helpful. For instance early readmissions may be
more a reflection of hospital quality than skilled nursing facility quality.
Also the unintended consequences may include a lack of appropriate access to
acute care when needed. AGS believes that there will need to be some effort to
measure the potential impact of such a measure on increased skilled nursing
facility mortality rates. Would use of the measure create undue data
collection or reporting burden? No Is there a better measure available or does
a measure already in the program set address a particular program objective?
No(Submitted by: American Geriatrics Society)
- We support this measure and agree with MAP Rationale that this measure is
well aligned with current readmission measures used in other settings. †The
description states the measure is limited to Medicare fee-for service
†beneficiaries, thus excluding nursing home residents who are receiving
nursing facility level of care, but perhaps hospice enrollment for symptom
management should also be specified as a denominator exclusion. There is no
description of the risk-standardization methodology on which to comment. Usual
risk adjusters include demographics and diagnoses; however, functional
impairment is a predictor of morbidity and mortality in older adults. CMS
engaged Research Triangle Institute in the development of Continuity
Assessment and Record Evaluation (CARE) Item Set, later truncated to B-CARE.
We suggest a comment that the risk-standardization methodology needs further
definition. We were surprised by no Outcomes Measure for improvement in
functional status, as most SNF admissions are to provide physical
rehabilitation services to address physical debility resulting from acute
illness. (Submitted by: Armstrong Institute for Patient Safety and
Quality)
- Although SHM does support the MAP recommendation for this measure, we
suggest considering alignment with the hospital readmission measures that are
condition-specific as opposed to a broad all-cause readmission measure. This
type of harmonization may provide more useful information on the performance
of a healthcare system, particularly those that are integrated with both acute
inpatient and post-acute facilities. Furthermore, we share the concerns of
some of the MAP members that the number and complexity of exclusions may make
it difficult to interpret results from this measure. (Submitted by: Society of
Hospital Medicine)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- It is ARNís understanding that it is the intention and desire of NQF to
align measures across the post-acute care continuum when possible. However,
there are different measures for the different PAC venues including IRH/Us and
SNFs. Measure 2502, All-Cause Unplanned Readmission Measure for 30 Days Post
Discharge from Inpatient Rehabilitation Facilities (IRFs) is based on data for
24 months of IRF discharges to non-hospital post-acute levels of care or to
the community while measure 2510, Skilled Nursing Facility 30-Day All-Cause
Readmission Measure (SNFRM) is based on 12 months of data. There should not be
such disconnect if the original intent of NQFís recommendation and selection
of measures was to be both harmonious and parsimonious. We would encourage the
committee to examine the measures across the PAC continuum for opportunities
for alignment. While we appreciate the work of the committee, we strongly
disagree with the exclusion criteria for SNF stays where the patient had one
or more intervening post-acute care (PAC) admissions to an IRF which occurred
either between the prior proximal hospital discharge and SNF admission or
after the SNF discharge, within the 30-day risk window. The exclusion
criteria would not take into account a medically complex patient that is
treated in an IRF and then readmitted within 30 days for an issue that may
have been treated as a co-morbidity. We believe that IRFs should be considered
a proximal hospitalization and disagree with the rationale provided for
exclusion, that these patients are clinically different. As determined in a
recent OIG report, the readmission rate for SNFs is both problematic and
concerning. The report found that an estimated 22 percent of Medicare
beneficiaries experienced adverse events during their SNF stays and an
additional 11 percent of Medicare beneficiaries experienced temporary harm
events during their SNF stays. Over half of the residents who experienced harm
returned to a hospital for treatment, with an estimated cost to Medicare of
$208 million in August 2011. This equates to $2.8 billion spent on hospital
treatment for harm caused in SNFs in FY 2011 (OIG, 2014). Readmission rates
for IRFs do vary but are nowhere near the SNF rate. A study by Ottenbacher et
al. (2012, 2014) found that the 30-day readmission rates for the six largest
diagnostic impairment categories (stroke, lower extremity fracture, lower
extremity joint replacement, debility, neurologic disorders and brain
dysfunction) was 11.8 percent with 50 percent of readmissions occurring within
11 days of discharge from the IRF. We also disagree with the 30-day
readmission data utilized from claims data. Determining readmission rates will
be difficult for IRFs or other post-acute settings to discern as claims data
are cumbersome to use and access. Utilizing this indicator will not provide
meaningful insight or have an impact on quality improvement efforts if the
settings do not have access to the data. (Submitted by: Association of
Rehabilitation Nurses)
- American Health Care Association (AHCA) is submitting comments on MAP
measure s2510 Skilled Nursing Facility All-Cause 30 Day Post Discharge
Readmission Measure. AHCA has concerns with the use of this measure for
several reasons. First, this measure only captures readmission rates for
Medicare fee for service (FFS) beneficiaries. For approximately 9,800 of the
15,000+ skilled nursing facilities (SNFs) in the country, Medicare FFS
admissions comprise less or equal to 70 percent of their total admissions;
with nearly 50% having less than or equal to 50 percent of their admissions as
Medicare FFS (see Table 1). In general, when data is not available on 30% or
more of a population; the measures may not be representative. So a FFS
Medicare only measure has missing data for all non-Medicare FFS admissions
which this table shows is very prevalent in SNFs. Thus, measure s2510 can be
very misleading when evaluating the readmission rate for a SNF. Second, this
measure captures readmissions that occur both during and after SNF discharge.
The SNF value based purchasing program is designed to address readmissions
during the SNF stay and this measure and this measure is not consistent with
this. Third, this measure does not capture hospital admissions classified as
observation status since it utilizes Medicare Part A claims. These admissions
contribute both to the morbidity of patients and Medicare costs and should be
included. Fourth, this measure uses a predicted actual for the numerator
which adjusts the actual readmission rate based on bed size. This has the
effect of muting differences in rates for smaller SNFs. It also makes
interpreting this measure much more difficult by providers, public and payors.
Fifth, this measure can only risk adjust for diagnoses and demographic
characteristics available on claims. However, diagnoses alone do not capture
illness severity, functional status and clinical symptoms which are strong
predictors of hospital readmissions. We recommend that MAP look at NQF
endorsed measure 2375 PointRight Æ Pro 30ô before taking a position on measure
s2510. NQF measure 2375 is a MDS based measure that captures all patients
regardless of payor type and observation admissions. Additionally, it risk
adjusts for functional and clinical symptoms as well as demographics and
diagnoses.
|Cumulative |Cumulative %of Admissions that are
Medicare| Number of Facilities| %of Facilities Exactly 0%
| 24 | 0% =10%
|152 | 1% =20%
|636 |
5% =30% |1,717
| 15% =40% |3,548
| 30% =50% |5,831
| 50% =60%
|8,058 | 69% =70%
|9,843 | 84% =80%
|10,991 | 94% =90%
|11,536 | 98% =100%
|11,726 | 100% (Submitted
by: American Health Care Association )
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
| (Program: Medicare Shared Savings Program; MUC ID:
S2521) |
- We regret that NQF did not approve this measure for trial use, but the ACR
still strongly believes this is an important measure. We would like to restate
the evidence demonstrating strong association between serum urate levels and
patient outcomes (gout attacks and tophi resolution). Shoji and colleagues
reported that patients with serum urate < 6 mg/dl had < 20% probability
of having a gout flare during the year, whereas patients with serum urate >
8 mg/dl had > 70% chance of having a gout flare. Shoji A, Yamanaka H,
Kamatani N. ìA retrospective study of the relationship between serum urate
level and recurrent attacks of gouty arthritis: evidence for reduction of
recurrent gouty arthritis with antihyperuricemic therapy.î Arthritis Rheum.
2004 Jun 15;51(3):321-5. Perez-Ruiz and colleagues demonstrated that speed of
tophus resolution is associated with serum urate levels with lower levels of
serum urate associated with more rapid resolution, higher levels of serum
urate associated with growth in tophus size. Perez-Ruiz F, Calabozo M, Pijoan
JI, Herrero-Beites AM, Ruibal A. Effect of urate-lowering therapy on the
velocity of size reduction of tophi in chronic gout. Arthritis Rheum 2002; 47:
356ñ60. Additionally, patients in a managed care setting with higher baseline
serum urate predict higher healthcare costs and gout related healthcare costs.
(Halpern R) Halpern R, Mody RR, Fuldeore MJ, Patel PA, Mikuls TR. ìImpact of
noncompliance with urate-lowering drug on serum urate and gout-related
healthcare costs: administrative claims analysis.î Curr Med Res Opin. 2009
Jul;25(7):1711-9. The ACR recognizes a huge variation in understanding the
mechanisms of gout, best practices and available evidence between
rheumatologists and other specialties. This discrepancy and gap of
understanding confirms the importance of this measure, as our evidence shows a
strong correlation between urate levels and patient outcomes. We further
document that there are large gaps in quality looking at current practices. In
a study by Perez-Ruiz and colleagues, less than 3% of gouty patients received
doses of allopurinol in excess of 300 mg. However, the mean final dose of
allopurinol needed to achieve a target of less than 6.0 mg/dL is more than 370
mg/d. Perez-Ruiz F, Alonso-Ruiz A, Calabozo M, et al. Efficacy of allopurinol
and benzbromarone for the control of hyperuricemia. A pathogenic approach to
the treatment of primary chronic gout. Ann Rheum Disease 1998; 57:545ñ549. In
a separate study, most patients (n = 58/60) remained on the starting dose of
allopurinol and, of these patients, only 19 (33%) had an SUA < 6 mg /dl.
Elizabeth Cottrell*, Valerie Crabtree, John J Edwards and Edward Roddy
ìImprovement in the management of gout is vital and overdue: an audit from a
UK primary care medical practice.î BMC Family Practice 2013, 14:170 (Submitted
by: American College of Rheumatology)
| (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: S2521) |
- We regret that NQF did not approve this measure for trial use, but the ACR
still strongly believes this is an important measure. We would like to restate
the evidence demonstrating strong association between serum urate levels and
patient outcomes (gout attacks and tophi resolution). Shoji and colleagues
reported that patients with serum urate < 6 mg/dl had < 20% probability
of having a gout flare during the year, whereas patients with serum urate >
8 mg/dl had > 70% chance of having a gout flare. Shoji A, Yamanaka H,
Kamatani N. ìA retrospective study of the relationship between serum urate
level and recurrent attacks of gouty arthritis: evidence for reduction of
recurrent gouty arthritis with antihyperuricemic therapy.î Arthritis Rheum.
2004 Jun 15;51(3):321-5. Perez-Ruiz and colleagues demonstrated that speed of
tophus resolution is associated with serum urate levels with lower levels of
serum urate associated with more rapid resolution, higher levels of serum
urate associated with growth in tophus size. Perez-Ruiz F, Calabozo M, Pijoan
JI, Herrero-Beites AM, Ruibal A. Effect of urate-lowering therapy on the
velocity of size reduction of tophi in chronic gout. Arthritis Rheum 2002; 47:
356ñ60. Additionally, patients in a managed care setting with higher baseline
serum urate predict higher healthcare costs and gout related healthcare costs.
(Halpern R) Halpern R, Mody RR, Fuldeore MJ, Patel PA, Mikuls TR. ìImpact of
noncompliance with urate-lowering drug on serum urate and gout-related
healthcare costs: administrative claims analysis.î Curr Med Res Opin. 2009
Jul;25(7):1711-9. The ACR recognizes a huge variation in understanding the
mechanisms of gout, best practices and available evidence between
rheumatologists and other specialties. This discrepancy and gap of
understanding confirms the importance of this measure, as our evidence shows a
strong correlation between urate levels and patient outcomes. We further
document that there are large gaps in quality looking at current practices. In
a study by Perez-Ruiz and colleagues, less than 3% of gouty patients received
doses of allopurinol in excess of 300 mg. However, the mean final dose of
allopurinol needed to achieve a target of less than 6.0 mg/dL is more than 370
mg/d. Perez-Ruiz F, Alonso-Ruiz A, Calabozo M, et al. Efficacy of allopurinol
and benzbromarone for the control of hyperuricemia. A pathogenic approach to
the treatment of primary chronic gout. Ann Rheum Disease 1998; 57:545ñ549. In
a separate study, most patients (n = 58/60) remained on the starting dose of
allopurinol and, of these patients, only 19 (33%) had an SUA < 6 mg /dl.
Elizabeth Cottrell*, Valerie Crabtree, John J Edwards and Edward Roddy
ìImprovement in the management of gout is vital and overdue: an audit from a
UK primary care medical practice.î BMC Family Practice 2013, 14:170 (Submitted
by: American College of Rheumatology)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: S2521) |
- Would addition of the measure add value to the program measure set? No
What is the measureís potential to improve patient outcomes? None Would use
of the measure create undue data collection or reporting burden? No, but there
is little or no clinical data to support its use. Is there a better measure
available or does a measure already in the program set address a particular
program objective? No(Submitted by: American Geriatrics
Society)
| (Program: Medicare Shared Savings Program; MUC ID: S2550)
|
- The ACR appreciates the support from MAP for continued development of this
measure and agree with the notes from the MAP rationale that gout is a
prevalent condtion and an area that warrants more quality measures. We believe
it would be a positive first step to include this measure in Federal programs,
particularly PQRS as a start. (Submitted by: American College of
Rheumatology)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: S2550) |
- The ACR appreciates the support from MAP for continued development of this
measure and agree with the notes from the MAP rationale that gout is a
prevalent condtion and an area that warrants more quality measures. We believe
it would be a positive first step to include this measure in Federal programs,
particularly PQRS as a start. (Submitted by: American College of
Rheumatology)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: S2550) |
- The ACR appreciates the support from MAP for continued development of this
measure and agree with the notes from the MAP rationale that gout is a
prevalent condtion and an area that warrants more quality measures. We believe
it would be a positive first step to include this measure in Federal programs,
particularly PQRS as a start. (Submitted by: American College of
Rheumatology)
- We regret that NQF did not approve this measure for trial use, but the ACR
still strongly believes this is an important measure. We would like to restate
the evidence demonstrating strong association between serum urate levels and
patient outcomes (gout attacks and tophi resolution). Shoji and colleagues
reported that patients with serum urate < 6 mg/dl had < 20% probability
of having a gout flare during the year, whereas patients with serum urate >
8 mg/dl had > 70% chance of having a gout flare. Shoji A, Yamanaka H,
Kamatani N. ìA retrospective study of the relationship between serum urate
level and recurrent attacks of gouty arthritis: evidence for reduction of
recurrent gouty arthritis with antihyperuricemic therapy.î Arthritis Rheum.
2004 Jun 15;51(3):321-5. Perez-Ruiz and colleagues demonstrated that speed of
tophus resolution is associated with serum urate levels with lower levels of
serum urate associated with more rapid resolution, higher levels of serum
urate associated with growth in tophus size. Perez-Ruiz F, Calabozo M, Pijoan
JI, Herrero-Beites AM, Ruibal A. Effect of urate-lowering therapy on the
velocity of size reduction of tophi in chronic gout. Arthritis Rheum 2002; 47:
356ñ60. Additionally, patients in a managed care setting with higher baseline
serum urate predict higher healthcare costs and gout related healthcare costs.
(Halpern R) Halpern R, Mody RR, Fuldeore MJ, Patel PA, Mikuls TR. ìImpact of
noncompliance with urate-lowering drug on serum urate and gout-related
healthcare costs: administrative claims analysis.î Curr Med Res Opin. 2009
Jul;25(7):1711-9. The ACR recognizes a huge variation in understanding the
mechanisms of gout, best practices and available evidence between
rheumatologists and other specialties. This discrepancy and gap of
understanding confirms the importance of this measure, as our evidence shows a
strong correlation between urate levels and patient outcomes. We further
document that there are large gaps in quality looking at current practices. In
a study by Perez-Ruiz and colleagues, less than 3% of gouty patients received
doses of allopurinol in excess of 300 mg. However, the mean final dose of
allopurinol needed to achieve a target of less than 6.0 mg/dL is more than 370
mg/d. Perez-Ruiz F, Alonso-Ruiz A, Calabozo M, et al. Efficacy of allopurinol
and benzbromarone for the control of hyperuricemia. A pathogenic approach to
the treatment of primary chronic gout. Ann Rheum Disease 1998; 57:545ñ549. In
a separate study, most patients (n = 58/60) remained on the starting dose of
allopurinol and, of these patients, only 19 (33%) had an SUA < 6 mg /dl.
Elizabeth Cottrell*, Valerie Crabtree, John J Edwards and Edward Roddy
ìImprovement in the management of gout is vital and overdue: an audit from a
UK primary care medical practice.î BMC Family Practice 2013, 14:170 (Submitted
by: American College of Rheumatology)
| (Program: Inpatient Rehabilitation
Facilities Quality Reporting Program; MUC ID: S2633) |
- As expressed in comments sent during the early comment period made
available by NQF in December 2014, we remain very concerned about the four
functional measures under consideration for federal programs. We appreciated
that the draft report reflects our recommendation to conditionally support the
measure until a variety of changes are made to the measure. As we noted in our
comments, restoring patient function is one of the fundamental purposes of
inpatient rehabilitation hospitals and units. As it pertains to this measure,
it appears that the CARE tool is used to determine whether the patient should
be excluded from this measure. At this time the CARE tool is not used by the
industry for any purpose. In fact, an assessment tool known as the Inpatient
Rehabilitation Facility Patient Assessment Instrument (IRF PAI) is in use for
payment (and some quality) purposes. To expect IRH/Us to use one tool for
payment purposes (the IRF PAI) and a second tool for quality purposes (the
CARE Tool) is duplicative and imposes an unnecessary burden. We are also
concerned that use of the CARE Tool will require a significant amount of
training on the part of the industry. As a result, it would be inappropriate
to adopt the use of the CARE Tool prematurely and for such a specific purpose.
However, we do support the exclusion criteria for incomplete stays and stays
of less than three days. As development of this measure moves forward we
encourage the continued use of these exclusion criteria. (Submitted by:
American Medical Rehabilitation Providers Association)
- 1. We are concerned that FIM change or CARE change data will be used
without adjusting for medical complexity, particularly for medical populations
such as cancer, cardiac and transplant. Not doing so would unfairly penalize
rehabilitation units associated with tertiary hospitals that treat the sickest
patients. 2. The CARE is not a tool commonly used in CIIRP, has not been well
studied in CIIRP, and we are unsure of its validity in this population. 3.
There lacks a common tool to track functional status across the continuum of
care: acute inpatient, inpatient rehabilitation, sub-acute rehabilitation, and
outpatient settings. In the acute care and outpatient settings we question
that the FIM and CARE tools can be incorporated into clinical care given that
they have a significant time-to-complete burden and require specialized
training to administer. 4. We recommend adding hospital acquired pressure
sores as a measure to track. (Submitted by: Armstrong Institute for Patient
Safety and Quality)
- The IRF Quality Reporting System could be greatly enhanced by further
developing and expanding core measures such as mobility and self-care. ARN
supports these indicators with the caveat that they are risk-adjusted and
diagnosis/impairment group specific with definitive inclusion/exclusion
criteria. While we support these indicators, we do not agree with the
exclusion criteria for S2633-IRF Functional Outcome Measure: Change in
Self-Care Score for Medical Rehabilitation Patients. The exclusion criteria
for S2633 are as follows: 3) Patients in coma, persistent vegetative state,
complete teraplegia, and locked-in syndrome are excluded, because they may
have limited or less predictable self-care improvement. 4) Patients younger
than age 21. Both of these criteria are inappropriate for use because they
are not representative of the IRF setting. The patient population listed in
Criteria #3 is not usually admitted/treated in an IRF and most IRFs treat
patients younger than 21 if needed (the FIM instrument/IRF-PAI is for patients
7 and older). (Submitted by: Association of Rehabilitation
Nurses)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- UDSMR thanks the Measure Applications Partnership (MAP) Post-Acute
Care/Long-Term Care Workgroup for this opportunity to provide feedback
regarding the 2015 Measures under Consideration. We are concerned by the
committeeís lack of discussion of the concerns and findings below, which were
raised by multiple organizations and large stakeholder groups prior to the
last meeting on Friday, December 12, 2014. We believe that these key points
must be considered when aligning functional quality measures for
rehabilitation. Specifically, we will direct our comments to the following IRF
functional outcomes measures: ï Measure S2633: Change in Self-Care Score for
Medical Rehabilitation Patients ï Measure S2634: Change in Mobility Score for
Medical Rehabilitation Patients ï Measure S2635: Discharge Self-Care Score
for Medical Rehabilitation Patients ï Measure S2636: Discharge Mobility Score
for Medical Rehabilitation Patients UDSMR has carefully reviewed these
measures and all related materials provided as part of the measure submission
and consideration process. We have the following concerns related to the
potential implementation of this measure: 1. First, we are highly concerned
about the validity of these measures. The demonstration project (PAC PRD) that
developed them used a cross-sectional study design that collected patient data
on a single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measuresí reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures predict anything, such as
the likelihood of discharge to a community setting, resource utilization
(including the cost of care), the patientís length of stay in post-acute care,
the likelihood of readmission to acute care, or the appropriateness of
inpatient readmission (functional gain). If the measures cannot be
demonstrated to predict outcomes of interest, their value as a data collection
tool is highly questionable, especially for inpatient rehabilitation
facilities already heavily burdened by the administrative costs of data
collection. A strong rationale with compelling supportive data is needed but
has not yet been provided to the public. 2. The risk-adjustment methodology
appears to have been developed from a limited data set constructed as part of
the PAC PRD project. In contrast to the IRF statistics reported in the March
2014 MedPAC report, the sample utilized in the development of these measures
represents only 1% of all IRF Medicare cases and comes from just 3% of all
IRFs. This brings into question the measuresí ability to accurately represent
the IRF population. Some of the risk-adjustment coefficients were produced
from very small populations. (Several impairment groups include fewer than
thirty cases.) The reliability of such a severity-adjustment methodology is
highly questionable. The classification and regression tree models used for
the analyses required hundreds or thousands of cases to be considered
reliable. We caution CMS and the Post-Acute Care/Long-Term Care Workgroup to
carefully review the analyses, as proceeding with a risk-adjustment
methodology that was developed from twenty or thirty patients with brain
injury collected from two or three IRFs, and to use the results as a basis for
outcomes reporting or reimbursement in the future. 3. Adding to the concern
regarding the sample size used for the analyses, the data set used to develop
the measure is now between four and six years old. As the aforementioned March
2014 MedPAC report shows, impairment populations admitted to an IRF have
changed within the past two years. In the past, orthopedic patients were one
of the most prevalent groups treated in inpatient rehabilitation. At present,
the number of patients with an orthopedic condition has decreased
substantially, having been replaced in part by patients with neurologic
impairments. The data used to develop these measures does not account for this
shift in patient distribution. Given these concerns about the applicability of
these measures to the current IRF population, we question both their ability
to add value to the IRF program measure set and their ability to improve
patient outcomes. 4. We fully agree that function should be used as a quality
measure in the IRF venue, but we are concerned about the measuresí inclusion
of functional items that are very similar, bordering on duplicative, but not
analogous, to the FIM items that are currently assessed as part of the IRF-PAI
for payment purposes. The IRF-PAI utilizes the 18 item FIM tool which already
measures both ìchange inî and ìdischargeî mobility and self-care. If
parsimony is a goal, why approve the collection of additional items to measure
what is already being measured? Depending on the measure, implementing these
measures would require IRFs to collect an additional 7-15 functional items
that use a rating scale and a data collection timeline different from those
currently in place at IRFs. This would (1) increase the burden on the
provider, (2) cause confusion for clinicians, and (3) compromise the value and
utility of both quality reporting and payment systems. The functional items
currently used in the IRF-PAI are a collective data set that has been used to
predict length of stay, costs, and payment for over a decade. Even though
these measuresí functional items border on duplicating the FIM items, they
are, as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, the proposed measures use data from the PAC PRD project, which
was tasked with identifying items (functional, medical, or otherwise) for use
in a potential post-acute care standardized assessment instrument. To date,
the functional items identified as part of the PAC PRD project have not been
approved for use as part of a standardized assessment instrument within the
IRF population, and the research has not provided any evidence suggesting that
these items provide any additional value or predictability in regard to IRF
outcomes. 6. We believe that the time required to assess patients on both the
current functional items for payment (in the IRF-PAI) and the proposed
functional items for ìqualityî will take away from time spent on actual
patient care and could negatively affect patientsí outcomes. As a result, we
believe that these measures would place upon IRFs an undue burden related to
data collection and reporting for measures that (1) are very similar to
existing items already collected and (2) have not demonstrated any
improvement, greater predictability of outcomes, or added value for patients
or IRFs. In other words, how will the proposed measure improve patient
outcomes over what is presently in place? Improvements in measuring or
collecting data that has not previously been collected are warranted, but
demonstrating the extent of improvement is equally necessary. Otherwise, the
effect of adding measures may be the opposite of what is intended. Data may
become unreliable or, as mentioned above, clinicians may spend more time
completing paperwork and less time providing care and rehabilitation to their
patients. UDSMR believes that any quality measures used in the inpatient
rehabilitation setting must take into account the overriding goal of
rehabilitation, which is to decrease the burden of care among individuals
requiring rehabilitation, thereby allowing patients to return to a community
setting. UDSMR urges CMS and the MAP Post-Acute Care/Long-Term Care Workgroup
to carefully consider the limitations inherent in the proposed measures under
consideration and to consider using measures currently in place with a proven
history of strong performance. (Submitted by: Uniform Data System for Medical
Rehabilitation)
- [Pre-workgroup meeting comment] Restoring patient function is one
of the fundamental purposes of inpatient rehabilitation hospitals and units.
Unfortunately, the functional measures under consideration by the MAP are not
ready for implementation at this time for a variety of reasons. As it pertains
to this measure, it appears that the CARE tool is used to determine whether
the patient should be excluded from this measure. At this time the CARE tool
is not used by the industry for any purpose. In fact, an assessment tool known
as the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF
PAI) is in use for payment (and some quality) purposes. To expect IRH/Us to
use one functional tool for payment purposes (the FIM tool on the IRF PAI) and
a second tool for quality purposes (the CARE Tool) is duplicative and imposes
an unnecessary burden and potential for error. We are also concerned that use
of the CARE Tool will require a significant amount of training on the part of
the industry. As a result, it would be inappropriate to adopt the use of the
CARE Tool prematurely and for such a specific purpose. Additionally the
numerator and denominator for the measure do not appear to make sense
indicating that more patients discharged would lead to a lower measure score.
Also, the measure needs risk adjustment to protect access for vulnerable
populations. However, we do support the exclusion criteria for incomplete
stays and stays of less than three days. As development of this measure moves
forward we encourage the continued use of these exclusion criteria.
(Submitted by: American Medical Rehabilitation Providers
Association)
- [Pre-workgroup meeting comment] We thank the Measure Applications
Partnership (MAP) for this opportunity to provide feedback to guide the
Post-Acute Care/Long-Term Care Workgroup as it evaluates the IRF Functional
Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
(S2633) measure. UDSMR has carefully reviewed this measure and all related
materials provided as part of the measure submission and consideration
process. We have the following concerns related to the potential
implementation of this measure: 1. First, we are highly concerned about the
measureís validity. The demonstration project in which the measure was
developed used a cross-sectional study design that collected patient data on a
single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measureís reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures actually predict
anything, such as the likelihood of discharge to a community setting, resource
utilization (including cost of care), the patientís length of stay in
post-acute care, the likelihood of readmission to acute care, or the
appropriateness of inpatient readmission (functional gain). If the measure
cannot be demonstrated to predict outcomes of interest, its value as a data
collection tool is highly questionable, especially for inpatient
rehabilitation facilities already heavily burdened by the administrative costs
of data collection. A strong rationale with compelling supportive data is
needed but has not yet been provided to the general public. 2. The
risk-adjustment methodology appears to have been developed from a limited data
set constructed as part of the PAC PRD project. In contrast to the IRF
statistics reported in the March 2014 MedPAC report, the sample utilized in
the development of this measure represents only 1% of all IRF Medicare cases
and comes from just 3% of all IRFs. This brings into question the measureís
ability to be representative of the IRF population. Some of the
risk-adjustment coefficients were produced from very small populations.
(Several impairment groups have fewer than thirty cases.) The reliability of
such a severity-adjustment methodology is highly questionable because
classification and regression tree modeling, which was used for the analysis,
requires hundreds or thousands of cases to be considered. We caution CMS and
the Post-Acute Care/Long-Term Care Workgroup to carefully review the analyses,
as proceeding with a risk-adjustment methodology that was developed from
twenty or thirty patients with brain injury collected from two or three IRFs,
for instance, could have serious implications for IRF providers and could
negatively affect patientsí access to inpatient rehabilitation and quality of
care. 3. Adding to the concern regarding the sample size used for the
analyses, the data set used to develop the measure is now between four and six
years old. As the aforementioned March 2014 MedPAC report shows, impairment
populations admitted to an IRF have changed within the past two years. In the
past, orthopedic patients were one of the most prevalent groups treated in
inpatient rehabilitation. At present, the number of patients with an
orthopedic condition has decreased substantially, having been replaced in part
by patients with neurologic impairments. The data used in developing this
measure does not account for this shift in patient distribution. Given these
concerns about the applicability of this measure to the current IRF
population, we question both its ability to add value to the IRF program
measure set and its ability to improve patient outcomes. 4. We are concerned
about the measureís inclusion of functional items that are very similar to,
but not analogous to, the FIMÆ items that are currently assessed as part of
the IRF-PAI for payment purposes. (The IRF-PAI uses the eighteen-item FIMÆ
instrument, which already measures both mobility and self-care.)
Implementation of measure S2633 would require the collection of an additional
seven functional items that utilize a rating scale and a data collection
timeline that differ from those currently in place at IRFs. This would (1)
increase the burden on the provider, (2) cause confusion for clinicians, and
(3) compromise the value and utility of quality reporting and payment systems.
The functional items currently used in the IRF-PAI are a collective data set
that has been used to predict length of stay, costs, and payment. Even though
the measureís functional items border on duplicating the FIMÆ items, they are,
as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, this measure utilized data from the PAC PRD project, which was
tasked with identifying items (functional, medical, or otherwise) for
utilization in a potential post-acute care standardized assessment instrument.
The research on the measure does not provide evidence to suggest that the
functional items within the proposed measure provide any additional value or
predictability in regard to IRF outcomes. Additionally, because these items
may be considered similar to or duplicative of FIMÆ items currently assessed
in IRFs, we are concerned about both the burden of collecting and reporting
data for this measure and the potential for affecting the IRF-PAI data
currently utilized for payment as part of the IRF PPS. 6. We believe that the
time required to assess patients on both the current functional items for
payment (in the IRF-PAI) and the proposed functional items for ìqualityî will
take away from time spent on actual patient care and could negatively affect
patientsí outcomes. As a result, we believe that this measure would place upon
IRFs an undue burden related to data collection and reporting for a measure
that (1) is very similar to existing items already collected and (2) has not
demonstrated any improvement, greater predictability of outcomes, or added
value for patients or IRFs. In other words, how will the proposed measure
improve patient outcomes over what is presently in place? Improvements in
measuring or collecting data that has not previously been collected are
warranted, but demonstrating the extent of improvement is equally necessary.
Otherwise, the effect of adding measures may be the opposite of what is
intended. Data may become unreliable or, as mentioned above, clinicians may
spend more time completing paperwork and less time providing care and
rehabilitation to their patients. UDSMR believes that any quality measures
used in the inpatient rehabilitation setting must take into account the
overriding goal of rehabilitation, which is to decrease the burden of care
among individuals requiring rehabilitation, thereby allowing patients to
return to a community setting. UDSMR urges CMS and the Post-Acute
Care/Long-Term Care Workgroup to carefully consider the limitations inherent
in the measures under consideration.(Submitted by: Uniform Data System for
Medical Rehabilitation (UDSMR))
- [Pre-workgroup meeting comment] We agree with CMS that the IRF QRP
could be greatly enhanced by addressing IRF-specific core measure concepts and
safety issues. The most fundamental core measure for IRFs should pertain to
patientsí functional improvement and the ability to continue activities of
daily living upon discharge back to their communities. The functional
measures S2633, S2634, S2635, S2636 as proposed in the MUC list were developed
as part of the Continuity Assessment Record and Evaluation (ìCAREî) Tool.
However, the inpatient rehabilitation facility (IRF) community feels strongly
that the functional status measures as defined and reported through the UDSMR
ìFIMîÆ tool are stronger and more appropriate for IRFs. For more than two
decades and data produced the FIMÆ are already reported to CMS. The FIMÆ tool
is available to CMS free of charge and has been offered to NQF for perpetual
use, royalty free. Many IRFs have built the FIMÆ tool directly into their
record and payment systems and maintain a significant amount of historical
data. By modifying or changing the core measures already in standard use by
IRFs for patientsí functional improvement, even slightly, CMS would greatly
exhaust clinician and hospital resources as they attempt to adapt to the
special Medicare-only measures. The FIMÆ measure is also reported to CMS by
IRFs as part of the IRF Patient Assessment Instrument (ìIRF-PAIî) reporting
process as required under applicable statutes and regulations governing the
Inpatient Rehabilitation Facility Prospective Payment System (ìIRF PPSî). It
is also unclear whether the proposed functional measures will replace the FIMÆ
measure entirely, or will be used alongside the FIMÆ measures, possibly as a
mere quality indicator (in addition to the IRF-PAI). Using these proposed
functional measures alongside FIMÆ would create two similar, but fundamentally
different, functional rating scales. This would cause confusion among IRF
practitioners and clinicians. Having two measures of function for each patient
would be overly confusing and burdensome, and could easily confound patients
who try to understand how to meet specific functional goals. The proposed
CARE Tool functional measures are not as sensitive to differentiating patient
functional level as FIMÆ. The CARE Tool item set and the proposed functional
measures have only six levels of function, one level less than the existing
FIMÆ functional measure. This one-level difference makes the proposed
functional measures less differentiated among one another, and therefore less
capable of expressing a patientís precise functional status. As healthcare
strives to be more patient centered, these proposed CARE Tool functional
measures seem to shift the focus from the patient to the clinician by
describing the amount of work the clinician must complete in order to perform
the task. The unintended consequence of describing the burden of care from the
clinician perspective, rather than from the patient/family perspective, could
degrade the patient experience overall. Conversely, the FIMÆ measure approach
of looking at the amount of work the patient must perform in order to progress
through the FIMÆ levels shifts the focus closer to the patientís
individualized rehabilitation and therapy goals. The differences in the items
scored to indicate a patientís function do not support independence and/or a
transition to home. For example, the FIMÆ bowel and bladder score measures the
patientís ability to manage their bladder and the number of times an accident
occurs. An accident is defined as ìthe act of wetting linen or clothing with
urine, including bedpan and urinal spills.î This aspect of the FIMÆ measure
supports the general principle that a patientís independence can be achieved
by demonstrating the functional capacity to prevent incontinence (the loss of
bladder control) from wetting clothes or linen. Both the burden of care and
the outcome of that care remain with the patient. However, the CARE Item Set
measures incontinence regardless of whether or not the patient is able to
prevent soiling linen or clothing. This fundamental change in philosophy of
what constitutes independence has the potential to change the practice of
rehabilitation nursing, as the focus will no longer be on assisting patients
in managing their bladder issues.(Submitted by: Federation of American
Hospitals)
- [Pre-workgroup meeting comment] We agree with CMS that the IRF QRP
could be greatly enhanced by addressing IRF-specific core measure concepts and
safety issues. The most fundamental core measure for IRFs should pertain to
patientsí functional improvement and the ability to continue activities of
daily living upon discharge back to their communities. The functional
measures proposed as MUC were developed as part of the Continuity Assessment
Record and Evaluation (ìCAREî) Tool. However, the UDSMR ìFIMîÆ tool has been
in use by all IRFs for over two decades and data produced by it are already
reported to CMS. The FIMÆ tool is available to CMS free of charge and has been
offered to NQF for perpetual use, royalty free. Many IRFs have built the FIMÆ
tool directly into their record and payment systems and maintain a significant
amount of historical data. By modifying or changing the core measures already
in standard use by IRFs for patientsí functional improvement, even slightly,
CMS would greatly exhaust clinician and hospital resources as they attempt to
adapt to the special Medicare-only measures. STRENGTH OF EXISTING FUNCTIONAL
MEASURE Approving these functional measures for use in an IRF undercuts the
existing measures that is already in use by all IRFs. The FIMÆ functional
measure has been validated, accepted, and used by clinicians and medical
rehabilitation practitioners within all of Americaís rehabilitation hospitals
and hospital-based inpatient rehabilitation units (collectively known as
inpatient rehabilitation facilities, or ìIRFsî) for over two decades. The FIMÆ
measure is also reported to CMS by IRFs as part of the IRF Patient Assessment
Instrument (ìIRF-PAIî) reporting process as required under applicable statutes
and regulations governing the Inpatient Rehabilitation Facility Prospective
Payment System (ìIRF PPSî). In addition, the FIMÆ functional measure is
available for use on a royalty-free basis for the purpose of quality reporting
and along with other FIMÆ derivatives can be used across all post-acute care
and long-term care (ìPAC/LTCHî) settings. Modifying the core measure already
in standard use by IRFs and other rehabilitation providers for functional
improvement would greatly exhaust clinician and hospital resources,
particularly if the new functional measure was not substantially improved over
the existing measure. It is also unclear whether the proposed functional
measures will replace the FIMÆ measure entirely, or will be used alongside the
FIMÆ measures, possibly as a mere quality indicator (in addition to the
IRF-PAI). Using these proposed functional measures alongside FIMÆ would create
two similar, but fundamentally different, functional rating scales. This would
cause confusion among IRF practitioners and clinicians. Having two measures of
function for each patient would be overly confusing and burdensome, and could
easily confound patients who try to understand how to meet specific functional
goals. The proposed functional measures are not as sensitive to differing
patient functional level as FIMÆ. The CARE Tool item set and the proposed
functional measures have only six levels of function, one level less than the
existing FIMÆ functional measure. This one-level difference makes the proposed
functional measures less differentiated among one another, and therefore less
capable of expressing a patientís precise functional status. As healthcare
strives to be more patient centered, the proposed functional measures seem to
shift the focus from the patient to the clinician by describing the amount of
work the clinician must complete in order to perform the task. The unintended
consequence of describing the burden of care from the clinician perspective,
rather than from the patient/family perspective, could degrade the patient
experience overall. Conversely, the FIMÆ measure approach of looking at the
amount of work the patient must perform in order to progress through the FIMÆ
levels shifts the focus closer to the patientís individualized rehabilitation
and therapy goals. The MUC functional measures (CARE Item Set) only have 6
levels of function, which is one level less than the existing FIMÆ functional
measure. This makes the CARE Item Set less differentiated, which would make it
a less sensitive tool compared to the FIMÆ functional measure. When selecting
a quality measure, the more sensitive the tool ñ the more descriptive and
accurate the quality measure will be. Additionally, as healthcare strives to
be more patient centered, the CARE Item Set seems to shift the focus from the
patient to the clinician by describing the amount of work the helper must do
to perform the task. The unintended consequence of describing the burden of
care from the clinician perspective, rather than from the patient/family
perspective, could degrade the patient experience. Conversely, the FIMÆ
measure approach of looking at the amount of work the patient performs moves
the focus closer to the patientís individual rehabilitation and therapy goals.
The differences in the items scored to indicate a patientís function do not
support independence and/or a transition to home. For example, the FIMÆ bowel
and bladder score measures the patientís ability to manage their bladder and
the number of times an accident occurs. An accident is defined as ìthe act of
wetting linen or clothing with urine, including bedpan and urinal spills.î
This aspect of the FIMÆ measure supports the general principle that a
patientís independence can be achieved by demonstrating the functional
capacity to prevent incontinence (the loss of bladder control) from wetting
clothes or linen. Both the burden of care, and the outcome of that care,
remain with the patient. By contrast, the CARE Item Set measure measures
incontinence regardless of whether or not the patient is able to prevent
soiling linen or clothing. This fundamental change in philosophy of what
constitutes independence has the potential to change the practice of
rehabilitation nursing, as the focus will no longer be on assisting patients
in managing their bladder issues. TECHNICAL ISSUE The two measures related to
mean change (self-care and mobility) do not appropriately calculate a mean.
The numerators ìmean change in mobility/self-careî over a denominator of
ìpatients dischargedî seems to inappropriately divide the average change of
the functional measure by the number of patients discharged by the facility.
This would cause discharge numbers to affect the mean functional change in a
non-relevant way. REGARDING THE FUNCTIONAL MEASURES UNDER CONSIDERATION -We
respectfully urge that careful consideration be given to the strength of the
FIMÆ measure as demonstrated by its clinical validity and broad acceptability
within and throughout the entire rehabilitation hospital sector. -FIMÆ
elements are reflective of a core principle embedded within the National
Quality Strategy, namely, ensuring that patients receive clear information
that can enable them to actively participate in their own care. Any measures
or instrument designed to examine patientsí functional outcomes should place
ample weight on the patient and their individual achievements; too much weight
assigned to the role of caregivers or clinicians could discourage such active
participation. -Simultaneous application of FIMÆ and new functional measures
would be overly burdensome and duplicative, and could result in conflicting
outcome results. (Submitted by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] We agree in principal with the
concept of using funcitonal outcome measures as quality measures for
inpatient rehabilitation hospitals. However, there are already functional
measures in use by IRFs that have been validated and accepted by the industry
and CMS that would be less burdensome for hospitals . (Submitted by:
Healthsouth)
- [Pre-workgroup meeting comment] I'm unsure why this and the other
functional outcome measures are being considered as quality measures for
Inpatient Rehabiltiation, when the industry already has a standard,
industry-accepted tool (FIM). It would be a significant burden to retrain
dozens of employees at each hospital on a similar (less sensitive) measure for
no positive benefit. If a better quality tool emerges to warrant such a
significant change to functional measure reporting in IRFs, I would support
such a move - but this seems like it's just changing a measure to change a
measure. Even these items are standardized for different post-acute settings,
they are all slightly unique - which means they are not comparable.
Additionally, IRFs have decades of FIM data to track and trend. Changing to
a new tool for no demonstrable reason means losing millions of valuable
records. Also, the calculation of the measure itself (mean change in
function/discharged patients) seems like a mistake. This would divide the
mean change over the number of patients. Which means two hospitals with the
same mean change could have their average affected by number of patients
admitted. This seems like an error.(Submitted by: HealthSouth
Corporation)
- [Pre-workgroup meeting comment] These comments pertain equally to
S2633 - S2366, because all four of these measures embrace the assumption that
an entirely new methodology for measuring patients' functional outcomes should
be adopted, despite the fact that clinicians in the field of rehabilitation
have been consistently and successfully using a well-validated functional
measurement tool for decades. This tool, known as FIM, has been the basis for
both academic research and clinical documentation. Having consistent,
longitudinal data is of immense importance in the field of quality
improvement. One reason the FIM data is such a gold mine is that CMS has
required the submission of admission and discharge FIM data on every single
patient for such a long time. To eradicate the value of such a rich data base
by switching to a new measurement tool is a huge price to pay for a change.
Obviously, such a change would have to offer incredibly important advantages
to overcome this loss. Frankly, CMS has not, to my knowledge, ever described
specifically what advantages it feels the CARE Tool's functional measures
offer over the well-researched FIM measures. Let me urge the MAP, before
acting to endorse any of these 4 functional measures that incorporate CARE
Tool metrics, to demand some convincing evidence that FIM measures have some
significant deficiencies that are resolved by the CARE functional measures.
It would be reasonable to expect CMS to provide a chart that specifically
identifies such "problems" and "solutions" before the MAP takes the entire
rehabilitation industry down the road of (1) increased expense to retrain tens
of thousands of clinicians in the entire rehabilitation sector, (2) losing
decades of comparative data, (3) risking deterioration in the quality of the
data because of user confusion (4) requiring total rebuilding of
rehabilitation-specific electronic medical records which have all embedded the
FIM tool. (It may be worth noting that EMR development in rehabilitation
hospitals has received no federal support since we are not eligible for HITECH
funding.) At one point, CMS may have pursued the creation of new functional
measures out of a belief that the FIM measures were proprietary and
unavailable; but that turned out not to be accurate. CMS also was looking for
a tool that could be used across settings; but the FIM tool could be used
across settings just as well as CARE's functional measures. And the current
measures under consideration are not proposed to be incorporated into
requirements for SNFs. To pursue a switch from FIM to CARE, with all of the
associated costs, without some certainty of dramatic benefits to be achieved,
works in opposition to MAP's mission. Functional improvement ---- and the
measurement of it --- lies at the foundation of rehabilitation medicine. Our
field has been a leader in outcome measurement, having developed and used the
FIM for decades. CMS's Quality Reporting Program should build on such
successes, not dismantle them. Sincerely, Dexanne B. Clohan, MD (Submitted
by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] My family members have been
patients in our rehab hospital and I'm concerned that a change from a good
functional measurement system to another system could decrease the quality of
care provided to patients while staff learn a whole new system. Plus
historical data from several decades could be lost. In addition, as an
employee, I am concerned about the tremendous cost in dollars and employee
time to learn a brand new system as well as the cost to modify the EMR built
around a current functional measure system.(Submitted by: HealthSouth
Corporation)
| (Program: Inpatient Rehabilitation
Facilities Quality Reporting Program; MUC ID: S2634) |
- As expressed in comments sent during the early comment period made
available by NQF in December 2014, we remain very concerned about the four
functional measures under consideration for federal programs. We appreciated
that the draft report reflects our recommendation to conditionally support the
measure until a variety of changes are made to the measure. As we noted in our
comments, as it pertains to this measure, it appears that the CARE tool is
used to determine whether the patient should be excluded from this measure. At
this time the CARE tool is not used by the industry for any purpose. In fact,
an assessment tool known as the Inpatient Rehabilitation Facility Patient
Assessment Instrument (IRF PAI) is in use for payment (and some quality)
purposes. To expect IRH/Us to use one tool for payment purposes (the IRF PAI)
and a second tool for quality purposes (the CARE Tool) is duplicative and
imposes an unnecessary burden. We are also concerned that use of the CARE Tool
will require a significant amount of training on the part of the industry. As
a result, it would be inappropriate to adopt the use of the CARE Tool
prematurely and for such a specific purpose. However, we do support the
exclusion criteria for incomplete stays and stays of less than three days. As
development of this measure moves forward we encourage the continued use of
these exclusion criteria. (Submitted by: American Rehabilitation Providers
Association)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- 1. We are concerned that FIM change or CARE change data will be used
without adjusting for medical complexity, particularly for medical populations
such as cancer, cardiac and transplant. Not doing so would unfairly penalize
rehabilitation units associated with tertiary hospitals that treat the sickest
patients. 2. The CARE is not a tool commonly used in CIIRP, has not been well
studied in CIIRP, and we are unsure of its validity in this population. 3.
There lacks a common tool to track functional status across the continuum of
care: acute inpatient, inpatient rehabilitation, sub-acute rehabilitation, and
outpatient settings. In the acute care and outpatient settings we question
that the FIM and CARE tools can be incorporated into clinical care given that
they have a significant time-to-complete burden and require specialized
training to administer. 4. We recommend adding hospital acquired pressure
sores as a measure to track. (Submitted by: Armstrong Institute for Patient
Safety and Quality)
- UDSMR thanks the Measure Applications Partnership (MAP) Post-Acute
Care/Long-Term Care Workgroup for this opportunity to provide feedback
regarding the 2015 Measures under Consideration. We are concerned by the
committeeís lack of discussion of the concerns and findings below, which were
raised by multiple organizations and large stakeholder groups prior to the
last meeting on Friday, December 12, 2014. We believe that these key points
must be considered when aligning functional quality measures for
rehabilitation. Specifically, we will direct our comments to the following IRF
functional outcomes measures: ï Measure S2633: Change in Self-Care Score for
Medical Rehabilitation Patients ï Measure S2634: Change in Mobility Score for
Medical Rehabilitation Patients ï Measure S2635: Discharge Self-Care Score
for Medical Rehabilitation Patients ï Measure S2636: Discharge Mobility Score
for Medical Rehabilitation Patients UDSMR has carefully reviewed these
measures and all related materials provided as part of the measure submission
and consideration process. We have the following concerns related to the
potential implementation of this measure: 1. First, we are highly concerned
about the validity of these measures. The demonstration project (PAC PRD) that
developed them used a cross-sectional study design that collected patient data
on a single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measuresí reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures predict anything, such as
the likelihood of discharge to a community setting, resource utilization
(including the cost of care), the patientís length of stay in post-acute care,
the likelihood of readmission to acute care, or the appropriateness of
inpatient readmission (functional gain). If the measures cannot be
demonstrated to predict outcomes of interest, their value as a data collection
tool is highly questionable, especially for inpatient rehabilitation
facilities already heavily burdened by the administrative costs of data
collection. A strong rationale with compelling supportive data is needed but
has not yet been provided to the public. 2. The risk-adjustment methodology
appears to have been developed from a limited data set constructed as part of
the PAC PRD project. In contrast to the IRF statistics reported in the March
2014 MedPAC report, the sample utilized in the development of these measures
represents only 1% of all IRF Medicare cases and comes from just 3% of all
IRFs. This brings into question the measuresí ability to accurately represent
the IRF population. Some of the risk-adjustment coefficients were produced
from very small populations. (Several impairment groups include fewer than
thirty cases.) The reliability of such a severity-adjustment methodology is
highly questionable. The classification and regression tree models used for
the analyses required hundreds or thousands of cases to be considered
reliable. We caution CMS and the Post-Acute Care/Long-Term Care Workgroup to
carefully review the analyses, as proceeding with a risk-adjustment
methodology that was developed from twenty or thirty patients with brain
injury collected from two or three IRFs, and to use the results as a basis for
outcomes reporting or reimbursement in the future. 3. Adding to the concern
regarding the sample size used for the analyses, the data set used to develop
the measure is now between four and six years old. As the aforementioned March
2014 MedPAC report shows, impairment populations admitted to an IRF have
changed within the past two years. In the past, orthopedic patients were one
of the most prevalent groups treated in inpatient rehabilitation. At present,
the number of patients with an orthopedic condition has decreased
substantially, having been replaced in part by patients with neurologic
impairments. The data used to develop these measures does not account for this
shift in patient distribution. Given these concerns about the applicability of
these measures to the current IRF population, we question both their ability
to add value to the IRF program measure set and their ability to improve
patient outcomes. 4. We fully agree that function should be used as a quality
measure in the IRF venue, but we are concerned about the measuresí inclusion
of functional items that are very similar, bordering on duplicative, but not
analogous, to the FIM items that are currently assessed as part of the IRF-PAI
for payment purposes. The IRF-PAI utilizes the 18 item FIM tool which already
measures both ìchange inî and ìdischargeî mobility and self-care. If
parsimony is a goal, why approve the collection of additional items to measure
what is already being measured? Depending on the measure, implementing these
measures would require IRFs to collect an additional 7-15 functional items
that use a rating scale and a data collection timeline different from those
currently in place at IRFs. This would (1) increase the burden on the
provider, (2) cause confusion for clinicians, and (3) compromise the value and
utility of both quality reporting and payment systems. The functional items
currently used in the IRF-PAI are a collective data set that has been used to
predict length of stay, costs, and payment for over a decade. Even though
these measuresí functional items border on duplicating the FIM items, they
are, as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, the proposed measures use data from the PAC PRD project, which
was tasked with identifying items (functional, medical, or otherwise) for use
in a potential post-acute care standardized assessment instrument. To date,
the functional items identified as part of the PAC PRD project have not been
approved for use as part of a standardized assessment instrument within the
IRF population, and the research has not provided any evidence suggesting that
these items provide any additional value or predictability in regard to IRF
outcomes. 6. We believe that the time required to assess patients on both the
current functional items for payment (in the IRF-PAI) and the proposed
functional items for ìqualityî will take away from time spent on actual
patient care and could negatively affect patientsí outcomes. As a result, we
believe that these measures would place upon IRFs an undue burden related to
data collection and reporting for measures that (1) are very similar to
existing items already collected and (2) have not demonstrated any
improvement, greater predictability of outcomes, or added value for patients
or IRFs. In other words, how will the proposed measure improve patient
outcomes over what is presently in place? Improvements in measuring or
collecting data that has not previously been collected are warranted, but
demonstrating the extent of improvement is equally necessary. Otherwise, the
effect of adding measures may be the opposite of what is intended. Data may
become unreliable or, as mentioned above, clinicians may spend more time
completing paperwork and less time providing care and rehabilitation to their
patients. UDSMR believes that any quality measures used in the inpatient
rehabilitation setting must take into account the overriding goal of
rehabilitation, which is to decrease the burden of care among individuals
requiring rehabilitation, thereby allowing patients to return to a community
setting. UDSMR urges CMS and the MAP Post-Acute Care/Long-Term Care Workgroup
to carefully consider the limitations inherent in the proposed measures under
consideration and to consider using measures currently in place with a proven
history of strong performance. (Submitted by: Uniform Data System for Medical
Rehabiltation)
- [Pre-workgroup meeting comment] Restoring patient function is one
of the fundamental purposes of inpatient rehabilitation hospitals and units.
Unfortunately, the functional measures under consideration by the MAP are not
ready for implementation at this time for a variety of reasons. As it pertains
to this measure, it appears that the CARE tool is used to determine whether
the patient should be excluded from this measure. At this time the CARE tool
is not used by the industry for any purpose. In fact, an assessment tool known
as the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF
PAI) is in use for payment (and some quality) purposes. To expect IRH/Us to
use one functional tool for payment purposes (the FIM tool on the IRF PAI) and
a second tool for quality purposes (the CARE Tool) is duplicative and imposes
an unnecessary burden and potential for error. We are also concerned that use
of the CARE Tool will require a significant amount of training on the part of
the industry. As a result, it would be inappropriate to adopt the use of the
CARE Tool prematurely and for such a specific purpose. Additionally the
numerator and denominator for the measure do not appear to make sense
indicating that more patients discharged would lead to a lower measure score.
Also, the measure needs risk adjustment to protect access for vulnerable
populations. However, we do support the exclusion criteria for incomplete
stays and stays of less than three days. As development of this measure moves
forward we encourage the continued use of these exclusion criteria.
(Submitted by: American Medical Rehabilitation Providers
Assocation)
- [Pre-workgroup meeting comment] We thank the Measure Applications
Partnership (MAP) for this opportunity to provide feedback to guide the
Post-Acute Care/Long-Term Care Workgroup as it evaluates the IRF Functional
Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients
(S2634) measure. UDSMR has carefully reviewed this measure and all related
materials provided as part of the measure submission and consideration
process. We have the following concerns related to the potential
implementation of this measure: 1. First, we are highly concerned about the
measureís validity. The demonstration project in which the measure was
developed used a cross-sectional study design that collected patient data on a
single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measureís reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures actually predict
anything, such as the likelihood of discharge to a community setting, resource
utilization (including cost of care), the patientís length of stay in
post-acute care, the likelihood of readmission to acute care, or the
appropriateness of inpatient readmission (functional gain). If the measure
cannot be demonstrated to predict outcomes of interest, its value as a data
collection tool is highly questionable, especially for inpatient
rehabilitation facilities already heavily burdened by the administrative costs
of data collection. A strong rationale with compelling supportive data is
needed but has not yet been provided to the general public. 2. The
risk-adjustment methodology appears to have been developed from a limited data
set constructed as part of the PAC PRD project. In contrast to the IRF
statistics reported in the March 2014 MedPAC report, the sample utilized in
the development of this measure represents only 1% of all IRF Medicare cases
and comes from just 3% of all IRFs. This brings into question the measureís
ability to be representative of the IRF population. Some of the
risk-adjustment coefficients were produced from very small populations.
(Several impairment groups have fewer than thirty cases.) The reliability of
such a severity-adjustment methodology is highly questionable because
classification and regression tree modeling, which was used for the analysis,
requires hundreds or thousands of cases to be considered. We caution CMS and
the Post-Acute Care/Long-Term Care Workgroup to carefully review the analyses,
as proceeding with a risk-adjustment methodology that was developed from
twenty or thirty patients with brain injury collected from two or three IRFs,
for instance, could have serious implications for IRF providers and could
negatively affect patientsí access to inpatient rehabilitation and quality of
care. 3. Adding to the concern regarding the sample size used for the
analyses, the data set used to develop the measure is now between four and six
years old. As the aforementioned March 2014 MedPAC report shows, impairment
populations admitted to an IRF have changed within the past two years. In the
past, orthopedic patients were one of the most prevalent groups treated in
inpatient rehabilitation. At present, the number of patients with an
orthopedic condition has decreased substantially, having been replaced in part
by patients with neurologic impairments. The data used in developing this
measure does not account for this shift in patient distribution. Given these
concerns about the applicability of this measure to the current IRF
population, we question both its ability to add value to the IRF program
measure set and its ability to improve patient outcomes. 4. We are concerned
about the measureís inclusion of functional items that are very similar to,
but not analogous to, the FIMÆ items that are currently assessed as part of
the IRF-PAI for payment purposes. (The IRF-PAI uses the eighteen-item FIMÆ
instrument, which already measures both mobility and self-care.)
Implementation of measure S2634 would require the collection of an additional
fifteen functional items that utilize a rating scale and a data collection
timeline that differ from those currently in place at IRFs. This would (1)
increase the burden on the provider, (2) cause confusion for clinicians, and
(3) compromise the value and utility of quality reporting and payment systems.
The functional items currently used in the IRF-PAI are a collective data set
that has been used to predict length of stay, costs, and payment. Even though
the measureís functional items border on duplicating the FIMÆ items, they are,
as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, this measure utilized data from the PAC PRD project, which was
tasked with identifying items (functional, medical, or otherwise) for
utilization in a potential post-acute care standardized assessment instrument.
The research on the measure does not provide evidence to suggest that the
functional items within the proposed measure provide any additional value or
predictability in regard to IRF outcomes. Additionally, because these items
may be considered similar to or duplicative of FIMÆ items currently assessed
in IRFs, we are concerned about both the burden of collecting and reporting
data for this measure and the potential for affecting the IRF-PAI data
currently utilized for payment as part of the IRF PPS. 6. We believe that the
time required to assess patients on both the current functional items for
payment (in the IRF-PAI) and the proposed functional items for ìqualityî will
take away from time spent on actual patient care and could negatively affect
patientsí outcomes. As a result, we believe that this measure would place upon
IRFs an undue burden related to data collection and reporting for a measure
that (1) is very similar to existing items already collected and (2) has not
demonstrated any improvement, greater predictability of outcomes, or added
value for patients or IRFs. In other words, how will the proposed measure
improve patient outcomes over what is presently in place? Improvements in
measuring or collecting data that has not previously been collected are
warranted, but demonstrating the extent of improvement is equally necessary.
Otherwise, the effect of adding measures may be the opposite of what is
intended. Data may become unreliable or, as mentioned above, clinicians may
spend more time completing paperwork and less time providing care and
rehabilitation to their patients. UDSMR believes that any quality measures
used in the inpatient rehabilitation setting must take into account the
overriding goal of rehabilitation, which is to decrease the burden of care
among individuals requiring rehabilitation, thereby allowing patients to
return to a community setting. UDSMR urges CMS and the Post-Acute
Care/Long-Term Care Workgroup to carefully consider the limitations inherent
in the measures under consideration.(Submitted by: Uniform Data System for
Medical Rehabilitation (UDSMR))
- [Pre-workgroup meeting comment] See comments for S2633(Submitted
by: Federation of American Hospitals)
- [Pre-workgroup meeting comment] We agree with CMS that the IRF QRP
could be greatly enhanced by addressing IRF-specific core measure concepts and
safety issues. The most fundamental core measure for IRFs should pertain to
patientsí functional improvement and the ability to continue activities of
daily living upon discharge back to their communities. The functional
measures proposed as MUC were developed as part of the Continuity Assessment
Record and Evaluation (ìCAREî) Tool. However, the UDSMR ìFIMîÆ tool has been
in use by all IRFs for over two decades and data produced by it are already
reported to CMS. The FIMÆ tool is available to CMS free of charge and has been
offered to NQF for perpetual use, royalty free. Many IRFs have built the FIMÆ
tool directly into their record and payment systems and maintain a significant
amount of historical data. By modifying or changing the core measures already
in standard use by IRFs for patientsí functional improvement, even slightly,
CMS would greatly exhaust clinician and hospital resources as they attempt to
adapt to the special Medicare-only measures. STRENGTH OF EXISTING FUNCTIONAL
MEASURE Approving these functional measures for use in an IRF undercuts the
existing measures that is already in use by all IRFs. The FIMÆ functional
measure has been validated, accepted, and used by clinicians and medical
rehabilitation practitioners within all of Americaís rehabilitation hospitals
and hospital-based inpatient rehabilitation units (collectively known as
inpatient rehabilitation facilities, or ìIRFsî) for over two decades. The FIMÆ
measure is also reported to CMS by IRFs as part of the IRF Patient Assessment
Instrument (ìIRF-PAIî) reporting process as required under applicable statutes
and regulations governing the Inpatient Rehabilitation Facility Prospective
Payment System (ìIRF PPSî). In addition, the FIMÆ functional measure is
available for use on a royalty-free basis for the purpose of quality reporting
and along with other FIMÆ derivatives can be used across all post-acute care
and long-term care (ìPAC/LTCHî) settings. Modifying the core measure already
in standard use by IRFs and other rehabilitation providers for functional
improvement would greatly exhaust clinician and hospital resources,
particularly if the new functional measure was not substantially improved over
the existing measure. It is also unclear whether the proposed functional
measures will replace the FIMÆ measure entirely, or will be used alongside the
FIMÆ measures, possibly as a mere quality indicator (in addition to the
IRF-PAI). Using these proposed functional measures alongside FIMÆ would create
two similar, but fundamentally different, functional rating scales. This would
cause confusion among IRF practitioners and clinicians. Having two measures of
function for each patient would be overly confusing and burdensome, and could
easily confound patients who try to understand how to meet specific functional
goals. The proposed functional measures are not as sensitive to differing
patient functional level as FIMÆ. The CARE Tool item set and the proposed
functional measures have only six levels of function, one level less than the
existing FIMÆ functional measure. This one-level difference makes the proposed
functional measures less differentiated among one another, and therefore less
capable of expressing a patientís precise functional status. As healthcare
strives to be more patient centered, the proposed functional measures seem to
shift the focus from the patient to the clinician by describing the amount of
work the clinician must complete in order to perform the task. The unintended
consequence of describing the burden of care from the clinician perspective,
rather than from the patient/family perspective, could degrade the patient
experience overall. Conversely, the FIMÆ measure approach of looking at the
amount of work the patient must perform in order to progress through the FIMÆ
levels shifts the focus closer to the patientís individualized rehabilitation
and therapy goals. The MUC functional measures (CARE Item Set) only have 6
levels of function, which is one level less than the existing FIMÆ functional
measure. This makes the CARE Item Set less differentiated, which would make it
a less sensitive tool compared to the FIMÆ functional measure. When selecting
a quality measure, the more sensitive the tool ñ the more descriptive and
accurate the quality measure will be. Additionally, as healthcare strives to
be more patient centered, the CARE Item Set seems to shift the focus from the
patient to the clinician by describing the amount of work the helper must do
to perform the task. The unintended consequence of describing the burden of
care from the clinician perspective, rather than from the patient/family
perspective, could degrade the patient experience. Conversely, the FIMÆ
measure approach of looking at the amount of work the patient performs moves
the focus closer to the patientís individual rehabilitation and therapy goals.
The differences in the items scored to indicate a patientís function do not
support independence and/or a transition to home. For example, the FIMÆ bowel
and bladder score measures the patientís ability to manage their bladder and
the number of times an accident occurs. An accident is defined as ìthe act of
wetting linen or clothing with urine, including bedpan and urinal spills.î
This aspect of the FIMÆ measure supports the general principle that a
patientís independence can be achieved by demonstrating the functional
capacity to prevent incontinence (the loss of bladder control) from wetting
clothes or linen. Both the burden of care, and the outcome of that care,
remain with the patient. By contrast, the CARE Item Set measure measures
incontinence regardless of whether or not the patient is able to prevent
soiling linen or clothing. This fundamental change in philosophy of what
constitutes independence has the potential to change the practice of
rehabilitation nursing, as the focus will no longer be on assisting patients
in managing their bladder issues. TECHNICAL ISSUE The two measures related to
mean change (self-care and mobility) do not appropriately calculate a mean.
The numerators ìmean change in mobility/self-careî over a denominator of
ìpatients dischargedî seems to inappropriately divide the average change of
the functional measure by the number of patients discharged by the facility.
This would cause discharge numbers to affect the mean functional change in a
non-relevant way. REGARDING THE FUNCTIONAL MEASURES UNDER CONSIDERATION -We
respectfully urge that careful consideration be given to the strength of the
FIMÆ measure as demonstrated by its clinical validity and broad acceptability
within and throughout the entire rehabilitation hospital sector. -FIMÆ
elements are reflective of a core principle embedded within the National
Quality Strategy, namely, ensuring that patients receive clear information
that can enable them to actively participate in their own care. Any measures
or instrument designed to examine patientsí functional outcomes should place
ample weight on the patient and their individual achievements; too much weight
assigned to the role of caregivers or clinicians could discourage such active
participation. -Simultaneous application of FIMÆ and new functional measures
would be overly burdensome and duplicative, and could result in conflicting
outcome results. (Submitted by: HealthSouth Corporation)
- [Pre-workgroup meeting comment] We agree in concept with the use of
functional measures. However, there are already industry standard measures
that could be used to avoid the unnecessary burden on hospitals rather than
changing to a new, less reliable tool. (Submitted by:
HealthSouth)
- [Pre-workgroup meeting comment] My family members have been
patients in our rehab hospital and I'm concerned that a change from a good
functional measurement system to another system could decrease the quality of
care provided to patients while staff learn a whole new system. Plus
historical data from several decades could be lost. In addition, as an
employee, I am concerned about the tremendous cost in dollars and employee
time to learn a brand new system as well as the cost to modify the EMR built
around a current functional measure system. (Submitted by: HealthSouth
Corporation)
| (Program: Inpatient Rehabilitation
Facilities Quality Reporting Program; MUC ID: S2635) |
- As expressed in comments sent during the early comment period made
available by NQF in December 2014, we remain very concerned about the four
functional measures under consideration for federal programs. We appreciated
that the draft report reflects our recommendation to conditionally support the
measure until a variety of changes are made to the measure. As we noted in our
comments, as it pertains to this measure, we need the measure steward to
clarify how the expected discharge score is to be developed. However, we do
support the exclusion criteria for incomplete stays and stays of less than
three days. As development of this measure moves forward we encourage the
continued use of these exclusion criteria. (Submitted by: American Medical
Rehabilitation Providers Association)
- We are wondering whether the words ìexpected discharge self-care scoreî
mean ìrisk adjusted.î The term ìrisk adjustedî was used in S2633 and S2634,
so we wondered why it wasnít used in this measure. Also, in terms of the
exclusions for the change in self-care function, it would be helpful to see
ìcomplete tetraplegiaî defined with the AIS scale. We are presuming that the
intent is to exclude ASIA A, but one could make the case that most patients
with ASIA B tetraplegia would have ìlimited or less predictableî self-care
improvement as well. (This was the terminology used to exclude patients in
coma.) We think that patients with tetraplegia, ASIA A and B be included in
the exclusions.(Submitted by: Magee Rehabilitation)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- 1. We are concerned that FIM change or CARE change data will be used
without adjusting for medical complexity, particularly for medical populations
such as cancer, cardiac and transplant. Not doing so would unfairly penalize
rehabilitation units associated with tertiary hospitals that treat the sickest
patients. 2. The CARE is not a tool commonly used in CIIRP, has not been well
studied in CIIRP, and we are unsure of its validity in this population. 3.
There lacks a common tool to track functional status across the continuum of
care: acute inpatient, inpatient rehabilitation, sub-acute rehabilitation, and
outpatient settings. In the acute care and outpatient settings we question
that the FIM and CARE tools can be incorporated into clinical care given that
they have a significant time-to-complete burden and require specialized
training to administer. 4. We recommend adding hospital acquired pressure
sores as a measure to track. (Submitted by: Armstrong Institute for Patient
Safety and Quality)
- [Pre-workgroup meeting comment] Restoring patient function is one
of the fundamental purposes of inpatient rehabilitation hospitals and units.
Unfortunately, the functional measures under consideration by the MAP are not
ready for implementation at this time for a variety of reasons. As it pertains
to this measure, we need the measure steward to clarify how the expected
discharge score is to be developed. Also, the measure needs risk adjustment
to protect access for vulnerable populations. However, we do support the
exclusion criteria for incomplete stays and stays of less than three days. As
development of this measure moves forward we encourage the continued use of
these exclusion criteria. (Submitted by: American Medical Rehabilitation
Providers Association)
- [Pre-workgroup meeting comment] We thank the Measure Applications
Partnership (MAP) for this opportunity to provide feedback to guide the
Post-Acute Care/Long-Term Care Workgroup as it evaluates the IRF Functional
Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients
(S2635) measure. UDSMR has carefully reviewed this measure and all related
materials provided as part of the measure submission and consideration
process. We have the following concerns related to the potential
implementation of this measure: 1. First, we are highly concerned about the
measureís validity. The demonstration project in which the measure was
developed used a cross-sectional study design that collected patient data on a
single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measureís reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures actually predict
anything, such as the likelihood of discharge to a community setting, resource
utilization (including cost of care), the patientís length of stay in
post-acute care, the likelihood of readmission to acute care, or the
appropriateness of inpatient readmission (functional gain). If the measure
cannot be demonstrated to predict outcomes of interest, its value as a data
collection tool is highly questionable, especially for inpatient
rehabilitation facilities already heavily burdened by the administrative costs
of data collection. A strong rationale with compelling supportive data is
needed but has not yet been provided to the general public. 2. The
risk-adjustment methodology appears to have been developed from a limited data
set constructed as part of the PAC PRD project. In contrast to the IRF
statistics reported in the March 2014 MedPAC report, the sample utilized in
the development of this measure represents only 1% of all IRF Medicare cases
and comes from just 3% of all IRFs. This brings into question the measureís
ability to be representative of the IRF population. Some of the
risk-adjustment coefficients were produced from very small populations.
(Several impairment groups have fewer than thirty cases.) The reliability of
such a severity-adjustment methodology is highly questionable because
classification and regression tree modeling, which was used for the analysis,
requires hundreds or thousands of cases to be considered. We caution CMS and
the Post-Acute Care/Long-Term Care Workgroup to carefully review the analyses,
as proceeding with a risk-adjustment methodology that was developed from
twenty or thirty patients with brain injury collected from two or three IRFs,
for instance, could have serious implications for IRF providers and could
negatively affect patientsí access to inpatient rehabilitation and quality of
care. 3. Adding to the concern regarding the sample size used for the
analyses, the data set used to develop the measure is now between four and six
years old. As the aforementioned March 2014 MedPAC report shows, impairment
populations admitted to an IRF have changed within the past two years. In the
past, orthopedic patients were one of the most prevalent groups treated in
inpatient rehabilitation. At present, the number of patients with an
orthopedic condition has decreased substantially, having been replaced in part
by patients with neurologic impairments. The data used in developing this
measure does not account for this shift in patient distribution. Given these
concerns about the applicability of this measure to the current IRF
population, we question both its ability to add value to the IRF program
measure set and its ability to improve patient outcomes. 4. We are concerned
about the measureís inclusion of functional items that are very similar to,
but not analogous to, the FIMÆ items that are currently assessed as part of
the IRF-PAI for payment purposes. (The IRF-PAI uses the eighteen-item FIMÆ
instrument, which already measures both mobility and self-care.)
Implementation of measure S2635 would require the collection of an additional
seven functional items that utilize a rating scale and a data collection
timeline that differ from those currently in place at IRFs. This would (1)
increase the burden on the provider, (2) cause confusion for clinicians, and
(3) compromise the value and utility of quality reporting and payment systems.
The functional items currently used in the IRF-PAI are a collective data set
that has been used to predict length of stay, costs, and payment. Even though
the measureís functional items border on duplicating the FIMÆ items, they are,
as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, this measure utilized data from the PAC PRD project, which was
tasked with identifying items (functional, medical, or otherwise) for
utilization in a potential post-acute care standardized assessment instrument.
The research on the measure does not provide evidence to suggest that the
functional items within the proposed measure provide any additional value or
predictability in regard to IRF outcomes. Additionally, because these items
may be considered similar to or duplicative of FIMÆ items currently assessed
in IRFs, we are concerned about both the burden of collecting and reporting
data for this measure and the potential for affecting the IRF-PAI data
currently utilized for payment as part of the IRF PPS. 6. We believe that the
time required to assess patients on both the current functional items for
payment (in the IRF-PAI) and the proposed functional items for ìqualityî will
take away from time spent on actual patient care and could negatively affect
patientsí outcomes. As a result, we believe that this measure would place upon
IRFs an undue burden related to data collection and reporting for a measure
that (1) is very similar to existing items already collected and (2) has not
demonstrated any improvement, greater predictability of outcomes, or added
value for patients or IRFs. In other words, how will the proposed measure
improve patient outcomes over what is presently in place? Improvements in
measuring or collecting data that has not previously been collected are
warranted, but demonstrating the extent of improvement is equally necessary.
Otherwise, the effect of adding measures may be the opposite of what is
intended. Data may become unreliable or, as mentioned above, clinicians may
spend more time completing paperwork and less time providing care and
rehabilitation to their patients. UDSMR believes that any quality measures
used in the inpatient rehabilitation setting must take into account the
overriding goal of rehabilitation, which is to decrease the burden of care
among individuals requiring rehabilitation, thereby allowing patients to
return to a community setting. UDSMR urges CMS and the Post-Acute
Care/Long-Term Care Workgroup to carefully consider the limitations inherent
in the measures under consideration.(Submitted by: Uniform Data System for
Medical Rehabilitation (UDSMR))
- [Pre-workgroup meeting comment] See comments for S2633(Submitted
by: Federation of American Hospitals)
- [Pre-workgroup meeting comment] We agree with CMS that the IRF QRP
could be greatly enhanced by addressing IRF-specific core measure concepts and
safety issues. The most fundamental core measure for IRFs should pertain to
patientsí functional improvement and the ability to continue activities of
daily living upon discharge back to their communities. The functional
measures proposed as MUC were developed as part of the Continuity Assessment
Record and Evaluation (ìCAREî) Tool. However, the UDSMR ìFIMîÆ tool has been
in use by all IRFs for over two decades and data produced by it are already
reported to CMS. The FIMÆ tool is available to CMS free of charge and has been
offered to NQF for perpetual use, royalty free. Many IRFs have built the FIMÆ
tool directly into their record and payment systems and maintain a significant
amount of historical data. By modifying or changing the core measures already
in standard use by IRFs for patientsí functional improvement, even slightly,
CMS would greatly exhaust clinician and hospital resources as they attempt to
adapt to the special Medicare-only measures. STRENGTH OF EXISTING FUNCTIONAL
MEASURE Approving these functional measures for use in an IRF undercuts the
existing measures that is already in use by all IRFs. The FIMÆ functional
measure has been validated, accepted, and used by clinicians and medical
rehabilitation practitioners within all of Americaís rehabilitation hospitals
and hospital-based inpatient rehabilitation units (collectively known as
inpatient rehabilitation facilities, or ìIRFsî) for over two decades. The FIMÆ
measure is also reported to CMS by IRFs as part of the IRF Patient Assessment
Instrument (ìIRF-PAIî) reporting process as required under applicable statutes
and regulations governing the Inpatient Rehabilitation Facility Prospective
Payment System (ìIRF PPSî). In addition, the FIMÆ functional measure is
available for use on a royalty-free basis for the purpose of quality reporting
and along with other FIMÆ derivatives can be used across all post-acute care
and long-term care (ìPAC/LTCHî) settings. Modifying the core measure already
in standard use by IRFs and other rehabilitation providers for functional
improvement would greatly exhaust clinician and hospital resources,
particularly if the new functional measure was not substantially improved over
the existing measure. It is also unclear whether the proposed functional
measures will replace the FIMÆ measure entirely, or will be used alongside the
FIMÆ measures, possibly as a mere quality indicator (in addition to the
IRF-PAI). Using these proposed functional measures alongside FIMÆ would create
two similar, but fundamentally different, functional rating scales. This would
cause confusion among IRF practitioners and clinicians. Having two measures of
function for each patient would be overly confusing and burdensome, and could
easily confound patients who try to understand how to meet specific functional
goals. The proposed functional measures are not as sensitive to differing
patient functional level as FIMÆ. The CARE Tool item set and the proposed
functional measures have only six levels of function, one level less than the
existing FIMÆ functional measure. This one-level difference makes the proposed
functional measures less differentiated among one another, and therefore less
capable of expressing a patientís precise functional status. As healthcare
strives to be more patient centered, the proposed functional measures seem to
shift the focus from the patient to the clinician by describing the amount of
work the clinician must complete in order to perform the task. The unintended
consequence of describing the burden of care from the clinician perspective,
rather than from the patient/family perspective, could degrade the patient
experience overall. Conversely, the FIMÆ measure approach of looking at the
amount of work the patient must perform in order to progress through the FIMÆ
levels shifts the focus closer to the patientís individualized rehabilitation
and therapy goals. The MUC functional measures (CARE Item Set) only have 6
levels of function, which is one level less than the existing FIMÆ functional
measure. This makes the CARE Item Set less differentiated, which would make it
a less sensitive tool compared to the FIMÆ functional measure. When selecting
a quality measure, the more sensitive the tool ñ the more descriptive and
accurate the quality measure will be. Additionally, as healthcare strives to
be more patient centered, the CARE Item Set seems to shift the focus from the
patient to the clinician by describing the amount of work the helper must do
to perform the task. The unintended consequence of describing the burden of
care from the clinician perspective, rather than from the patient/family
perspective, could degrade the patient experience. Conversely, the FIMÆ
measure approach of looking at the amount of work the patient performs moves
the focus closer to the patientís individual rehabilitation and therapy goals.
The differences in the items scored to indicate a patientís function do not
support independence and/or a transition to home. For example, the FIMÆ bowel
and bladder score measures the patientís ability to manage their bladder and
the number of times an accident occurs. An accident is defined as ìthe act of
wetting linen or clothing with urine, including bedpan and urinal spills.î
This aspect of the FIMÆ measure supports the general principle that a
patientís independence can be achieved by demonstrating the functional
capacity to prevent incontinence (the loss of bladder control) from wetting
clothes or linen. Both the burden of care, and the outcome of that care,
remain with the patient. By contrast, the CARE Item Set measure measures
incontinence regardless of whether or not the patient is able to prevent
soiling linen or clothing. This fundamental change in philosophy of what
constitutes independence has the potential to change the practice of
rehabilitation nursing, as the focus will no longer be on assisting patients
in managing their bladder issues. REGARDING THE FUNCTIONAL MEASURES UNDER
CONSIDERATION -We respectfully urge that careful consideration be given to the
strength of the FIMÆ measure as demonstrated by its clinical validity and
broad acceptability within and throughout the entire rehabilitation hospital
sector. -FIMÆ elements are reflective of a core principle embedded within the
National Quality Strategy, namely, ensuring that patients receive clear
information that can enable them to actively participate in their own care.
Any measures or instrument designed to examine patientsí functional outcomes
should place ample weight on the patient and their individual achievements;
too much weight assigned to the role of caregivers or clinicians could
discourage such active participation. -Simultaneous application of FIMÆ and
new functional measures would be overly burdensome and duplicative, and could
result in conflicting outcome results. (Submitted by: HealthSouth
Corporation)
- [Pre-workgroup meeting comment] We agree with the concept of using
funcitonal measures for quality reporting for IRFs. However, there are
already industry and CMS acceptable fuctional measures that could be used that
would not require retraining of staff, costly redesigning of EMRs and loss of
valuable historical/comparitive data. (Submitted by:
HealthSouth)
- [Pre-workgroup meeting comment] My family members have been
patients in our rehab hospital and I'm concerned that a change from a good
functional measurement system to another system could decrease the quality of
care provided to patients while staff learn a whole new system. Plus
historical data from several decades could be lost. In addition, as an
employee, I am concerned about the tremendous cost in dollars and employee
time to learn a brand new system as well as the cost to modify the EMR built
around a current functional measure system.(Submitted by: HealthSouth
Corporation)
| (Program: Inpatient Rehabilitation
Facilities Quality Reporting Program; MUC ID: S2636) |
- As expressed in comments sent during the early comment period made
available by NQF in December 2014, we remain very concerned about the four
functional measures under consideration for federal programs. We appreciated
that the draft report reflects our recommendation to conditionally support the
measure until a variety of changes are made to the measure. As we noted in our
comments, as it pertains to this measure, we need the measure steward to
clarify how the expected discharge score is to be developed. However, we do
support the exclusion criteria for incomplete stays and stays of less than
three days. As development of this measure moves forward we encourage the
continued use of these exclusion criteria. (Submitted by: American Medical
Rehabilitation Providers Association)
- We are wondering whether the words ìexpected discharge mobility scoreî
mean ìrisk adjusted.î The term ìrisk adjustedî was used in S2633 and S2634,
so we wondered why it wasnít used in this measure. Also, is it safe to assume
that patients with ASIA A or B tetraplegia were basically not ìexpectedî to
make much change in mobility, and that is why they were not specifically
excluded from the mobility measure?(Submitted by: Magee
Rehabilitation)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- 1. We are concerned that FIM change or CARE change data will be used
without adjusting for medical complexity, particularly for medical populations
such as cancer, cardiac and transplant. Not doing so would unfairly penalize
rehabilitation units associated with tertiary hospitals that treat the sickest
patients. 2. The CARE is not a tool commonly used in CIIRP, has not been well
studied in CIIRP, and we are unsure of its validity in this population. 3.
There lacks a common tool to track functional status across the continuum of
care: acute inpatient, inpatient rehabilitation, sub-acute rehabilitation, and
outpatient settings. In the acute care and outpatient settings we question
that the FIM and CARE tools can be incorporated into clinical care given that
they have a significant time-to-complete burden and require specialized
training to administer. 4. We recommend adding hospital acquired pressure
sores as a measure to track. (Submitted by: Armstrong Institute for Patient
Safety and Quality)
- [Pre-workgroup meeting comment] Restoring patient function is one
of the fundamental purposes of inpatient rehabilitation hospitals and units.
Unfortunately, the functional measures under consideration by the MAP are not
ready for implementation at this time for a variety of reasons. As it pertains
to this measure, we need the measure steward to clarify how the expected
discharge score is to be developed. Also, the measure needs risk adjustment to
protect access for vulnerable populations. However, we do support the
exclusion criteria for incomplete stays and stays of less than three days. As
development of this measure moves forward we encourage the continued use of
these exclusion criteria. (Submitted by: American Medical Rehabilitation
Providers Association)
- [Pre-workgroup meeting comment] We thank the Measure Applications
Partnership (MAP) for this opportunity to provide feedback to guide the
Post-Acute Care/Long-Term Care Workgroup as it evaluates the IRF Functional
Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients
(S2636) measure. UDSMR has carefully reviewed this measure and all related
materials provided as part of the measure submission and consideration
process. We have the following concerns related to the potential
implementation of this measure: 1. First, we are highly concerned about the
measureís validity. The demonstration project in which the measure was
developed used a cross-sectional study design that collected patient data on a
single post-acute stay. There is no data (medical or functional) from the
patientís acute stay and no information on any subsequent acute or post-acute
care utilization. This is problematic because aside from demonstrating the
measureís reliability (i.e., the stability and consistency of items), the
studyís design cannot determine whether the measures actually predict
anything, such as the likelihood of discharge to a community setting, resource
utilization (including cost of care), the patientís length of stay in
post-acute care, the likelihood of readmission to acute care, or the
appropriateness of inpatient readmission (functional gain). If the measure
cannot be demonstrated to predict outcomes of interest, its value as a data
collection tool is highly questionable, especially for inpatient
rehabilitation facilities already heavily burdened by the administrative costs
of data collection. A strong rationale with compelling supportive data is
needed but has not yet been provided to the general public. 2. The
risk-adjustment methodology appears to have been developed from a limited data
set constructed as part of the PAC PRD project. In contrast to the IRF
statistics reported in the March 2014 MedPAC report, the sample utilized in
the development of this measure represents only 1% of all IRF Medicare cases
and comes from just 3% of all IRFs. This brings into question the measureís
ability to be representative of the IRF population. Some of the
risk-adjustment coefficients were produced from very small populations.
(Several impairment groups have fewer than thirty cases.) The reliability of
such a severity-adjustment methodology is highly questionable because
classification and regression tree modeling, which was used for the analysis,
requires hundreds or thousands of cases to be considered. We caution CMS and
the Post-Acute Care/Long-Term Care Workgroup to carefully review the analyses,
as proceeding with a risk-adjustment methodology that was developed from
twenty or thirty patients with brain injury collected from two or three IRFs,
for instance, could have serious implications for IRF providers and could
negatively affect patientsí access to inpatient rehabilitation and quality of
care. 3. Adding to the concern regarding the sample size used for the
analyses, the data set used to develop the measure is now between four and six
years old. As the aforementioned March 2014 MedPAC report shows, impairment
populations admitted to an IRF have changed within the past two years. In the
past, orthopedic patients were one of the most prevalent groups treated in
inpatient rehabilitation. At present, the number of patients with an
orthopedic condition has decreased substantially, having been replaced in part
by patients with neurologic impairments. The data used in developing this
measure does not account for this shift in patient distribution. Given these
concerns about the applicability of this measure to the current IRF
population, we question both its ability to add value to the IRF program
measure set and its ability to improve patient outcomes. 4. We are concerned
about the measureís inclusion of functional items that are very similar to,
but not analogous to, the FIMÆ items that are currently assessed as part of
the IRF-PAI for payment purposes. (The IRF-PAI uses the eighteen-item FIMÆ
instrument, which already measures both mobility and self-care.)
Implementation of measure S2636 would require the collection of an additional
fifteen functional items that utilize a rating scale and a data collection
timeline that differ from those currently in place at IRFs. This would (1)
increase the burden on the provider, (2) cause confusion for clinicians, and
(3) compromise the value and utility of quality reporting and payment systems.
The functional items currently used in the IRF-PAI are a collective data set
that has been used to predict length of stay, costs, and payment. Even though
the measureís functional items border on duplicating the FIMÆ items, they are,
as noted earlier, not analogous, and items from one instrument or measure
cannot be switched with those in another without serious consequences. 5. As
noted above, this measure utilized data from the PAC PRD project, which was
tasked with identifying items (functional, medical, or otherwise) for
utilization in a potential post-acute care standardized assessment instrument.
The research on the measure does not provide evidence to suggest that the
functional items within the proposed measure provide any additional value or
predictability in regard to IRF outcomes. Additionally, because these items
may be considered similar to or duplicative of FIMÆ items currently assessed
in IRFs, we are concerned about both the burden of collecting and reporting
data for this measure and the potential for affecting the IRF-PAI data
currently utilized for payment as part of the IRF PPS. 6. We believe that the
time required to assess patients on both the current functional items for
payment (in the IRF-PAI) and the proposed functional items for ìqualityî will
take away from time spent on actual patient care and could negatively affect
patientsí outcomes. As a result, we believe that this measure would place upon
IRFs an undue burden related to data collection and reporting for a measure
that (1) is very similar to existing items already collected and (2) has not
demonstrated any improvement, greater predictability of outcomes, or added
value for patients or IRFs. In other words, how will the proposed measure
improve patient outcomes over what is presently in place? Improvements in
measuring or collecting data that has not previously been collected are
warranted, but demonstrating the extent of improvement is equally necessary.
Otherwise, the effect of adding measures may be the opposite of what is
intended. Data may become unreliable or, as mentioned above, clinicians may
spend more time completing paperwork and less time providing care and
rehabilitation to their patients. UDSMR believes that any quality measures
used in the inpatient rehabilitation setting must take into account the
overriding goal of rehabilitation, which is to decrease the burden of care
among individuals requiring rehabilitation, thereby allowing patients to
return to a community setting. UDSMR urges CMS and the Post-Acute
Care/Long-Term Care Workgroup to carefully consider the limitations inherent
in the measures under consideration.(Submitted by: Uniform Data System for
Medical Rehabilitation (UDSMR))
- [Pre-workgroup meeting comment] See comments on S2633(Submitted by:
Federation of American Hospitals)
- [Pre-workgroup meeting comment] We agree with CMS that the IRF QRP
could be greatly enhanced by addressing IRF-specific core measure concepts and
safety issues. The most fundamental core measure for IRFs should pertain to
patientsí functional improvement and the ability to continue activities of
daily living upon discharge back to their communities. The functional
measures proposed as MUC were developed as part of the Continuity Assessment
Record and Evaluation (ìCAREî) Tool. However, the UDSMR ìFIMîÆ tool has been
in use by all IRFs for over two decades and data produced by it are already
reported to CMS. The FIMÆ tool is available to CMS free of charge and has been
offered to NQF for perpetual use, royalty free. Many IRFs have built the FIMÆ
tool directly into their record and payment systems and maintain a significant
amount of historical data. By modifying or changing the core measures already
in standard use by IRFs for patientsí functional improvement, even slightly,
CMS would greatly exhaust clinician and hospital resources as they attempt to
adapt to the special Medicare-only measures. STRENGTH OF EXISTING FUNCTIONAL
MEASURE Approving these functional measures for use in an IRF undercuts the
existing measures that is already in use by all IRFs. The FIMÆ functional
measure has been validated, accepted, and used by clinicians and medical
rehabilitation practitioners within all of Americaís rehabilitation hospitals
and hospital-based inpatient rehabilitation units (collectively known as
inpatient rehabilitation facilities, or ìIRFsî) for over two decades. The FIMÆ
measure is also reported to CMS by IRFs as part of the IRF Patient Assessment
Instrument (ìIRF-PAIî) reporting process as required under applicable statutes
and regulations governing the Inpatient Rehabilitation Facility Prospective
Payment System (ìIRF PPSî). In addition, the FIMÆ functional measure is
available for use on a royalty-free basis for the purpose of quality reporting
and along with other FIMÆ derivatives can be used across all post-acute care
and long-term care (ìPAC/LTCHî) settings. Modifying the core measure already
in standard use by IRFs and other rehabilitation providers for functional
improvement would greatly exhaust clinician and hospital resources,
particularly if the new functional measure was not substantially improved over
the existing measure. It is also unclear whether the proposed functional
measures will replace the FIMÆ measure entirely, or will be used alongside the
FIMÆ measures, possibly as a mere quality indicator (in addition to the
IRF-PAI). Using these proposed functional measures alongside FIMÆ would create
two similar, but fundamentally different, functional rating scales. This would
cause confusion among IRF practitioners and clinicians. Having two measures of
function for each patient would be overly confusing and burdensome, and could
easily confound patients who try to understand how to meet specific functional
goals. The proposed functional measures are not as sensitive to differing
patient functional level as FIMÆ. The CARE Tool item set and the proposed
functional measures have only six levels of function, one level less than the
existing FIMÆ functional measure. This one-level difference makes the proposed
functional measures less differentiated among one another, and therefore less
capable of expressing a patientís precise functional status. As healthcare
strives to be more patient centered, the proposed functional measures seem to
shift the focus from the patient to the clinician by describing the amount of
work the clinician must complete in order to perform the task. The unintended
consequence of describing the burden of care from the clinician perspective,
rather than from the patient/family perspective, could degrade the patient
experience overall. Conversely, the FIMÆ measure approach of looking at the
amount of work the patient must perform in order to progress through the FIMÆ
levels shifts the focus closer to the patientís individualized rehabilitation
and therapy goals. The MUC functional measures (CARE Item Set) only have 6
levels of function, which is one level less than the existing FIMÆ functional
measure. This makes the CARE Item Set less differentiated, which would make it
a less sensitive tool compared to the FIMÆ functional measure. When selecting
a quality measure, the more sensitive the tool ñ the more descriptive and
accurate the quality measure will be. Additionally, as healthcare strives to
be more patient centered, the CARE Item Set seems to shift the focus from the
patient to the clinician by describing the amount of work the helper must do
to perform the task. The unintended consequence of describing the burden of
care from the clinician perspective, rather than from the patient/family
perspective, could degrade the patient experience. Conversely, the FIMÆ
measure approach of looking at the amount of work the patient performs moves
the focus closer to the patientís individual rehabilitation and therapy goals.
The differences in the items scored to indicate a patientís function do not
support independence and/or a transition to home. For example, the FIMÆ bowel
and bladder score measures the patientís ability to manage their bladder and
the number of times an accident occurs. An accident is defined as ìthe act of
wetting linen or clothing with urine, including bedpan and urinal spills.î
This aspect of the FIMÆ measure supports the general principle that a
patientís independence can be achieved by demonstrating the functional
capacity to prevent incontinence (the loss of bladder control) from wetting
clothes or linen. Both the burden of care, and the outcome of that care,
remain with the patient. By contrast, the CARE Item Set measure measures
incontinence regardless of whether or not the patient is able to prevent
soiling linen or clothing. This fundamental change in philosophy of what
constitutes independence has the potential to change the practice of
rehabilitation nursing, as the focus will no longer be on assisting patients
in managing their bladder issues. REGARDING THE FUNCTIONAL MEASURES UNDER
CONSIDERATION -We respectfully urge that careful consideration be given to the
strength of the FIMÆ measure as demonstrated by its clinical validity and
broad acceptability within and throughout the entire rehabilitation hospital
sector. -FIMÆ elements are reflective of a core principle embedded within the
National Quality Strategy, namely, ensuring that patients receive clear
information that can enable them to actively participate in their own care.
Any measures or instrument designed to examine patientsí functional outcomes
should place ample weight on the patient and their individual achievements;
too much weight assigned to the role of caregivers or clinicians could
discourage such active participation. -Simultaneous application of FIMÆ and
new functional measures would be overly burdensome and duplicative, and could
result in conflicting outcome results. (Submitted by: HealthSouth
Corporation)
- [Pre-workgroup meeting comment] We agree with the concept of using
functional outcomes as a quality measure for IRFs. However, there are already
measures available that have been validated and used by the IRF industry and
CMS for decades that should be considered that would prevent hospitals from
having to retrain staff, redesign their EMR systems and loose the valuable
historical/comparative data that currently exists. (Submitted by:
HealthSouth)
- [Pre-workgroup meeting comment] I amd the Director of Therapy
Operations for our free standing rehabiltation hospital. I am a Physical
Therapist by profewwion. Our hospital was one of the pilot sites for the CARE
Tool. I was one of the coordiators for the study. We were involved for 9
months with the study. During that time we had to use 2 differnet ourcome
tools, similar, but not the same. This caused confusion among the staff. The
FIM is a well know tool that is taught the therapy schools. I belive that the
CARE Tool outcome measures are not as inclusive as the FIM. The use of 2
different tools would be very burdesome and cause inaccurtate scoring. We
have a system with long history already in place, why change? Our company is
more that half way through the roll our of an EMR, we have been using ours
for 2 years. I was developed for us as there is not a systme out there geared
for IP rehab. We have the FIM as part of our program. We would need a
separate systme of get the information wihich would add an extra burden to
patietn care staff, taking them away from treatment of our patients. Why when
we already have a system in place. As the coordination for the pilot site for
9 months, I will let you know that the timing need for the documentation was a
hugh problem.. Please, PLEASE do not implement this, only problems will
exist.(Submitted by: Trinity Mother Frances Rehabiltation
Hospital)
- [Pre-workgroup meeting comment] My family members have been
patients in our rehab hospital and I'm concerned that a change from a good
functional measurement system to another system could decrease the quality of
care provided to patients while staff learn a whole new system. Plus
historical data from several decades could be lost. In addition, as an
employee, I am concerned about the tremendous cost in dollars and employee
time to learn a brand new system as well as the cost to modify the EMR built
around a current functional measure system.(Submitted by: HealthSouth
Corporation)
| (Program:
Physician Feedback; MUC ID: X0351) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues to
include only a 90-day "look-back period" for co-morbidities. This timeframe
should be aligned with other measures such as the mortality and readmission
measures that include 1 year. Additional analysis on the reliability and
validity of these measures is also needed before these measures are
conditionally endorsed for use within Medicareís physician-related value-based
payment provisions. It is difficult to evaluate whether the measures are
appropriate for adoption in light of this lack of information. Data on the
reliability of the measure specifications is needed and must be provided both
at the hospital and physician level. In addition and perhaps more
importantly, the validity of these measures must be demonstrated prior to
implementation in any pay-for-reporting or -performance program. While the
conditions may have presented as a higher proportion of Medicare patients, it
is unknown whether an individual hospital's sample size for some of these
conditions would be adequate to demonstrate clinically meaningful differences.
This concern only increases when considering implementing these measures at
the physician level. Finally, continuing to include cost of care measures in
the absence of accompanying quality measures addressing the same clinical
condition is contrary to NQF recommendations and the intent of the VBPM
program. We note that CMS withdrew many of these episode-based payment
measures from consideration in the Hospital Value-based Payment Program but
information on why is not provided. Applying these measures to physicians
without adequate review and testing would have significant negative unintended
consequences, particularly if they are not recommended for use in the level of
analysis for which they were developed.(Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] We are encouraged that CMS has
included condition-specific episode of care measures on the MUC list but,
until thorough validity and reliability testing has been performed in settings
of prospective use, we will continue to have concerns over these efficiency
measures. Specific to the Cellulitis and UTI measures, IDSA was never
formally asked to contribute expert volunteers to these cost measure
development panels despite the topic relevancy to ID-care. As a result, IDSA
is unsure to what extent they were developed with appropriate/ relevant
clinical expertise. In our comment letter, we recommended that CMS gradually
incorporate episode-based and condition-specific cost measures into federal
quality programs by initially using this data only for confidential provider
feedback reports. We feel this will give CMS and providers time to evaluate
and potentially make changes to the accuracy, relevance, and format of these
measures prior to using them for accountability purposes. Therefore we ask
that NQF consider evaluating this measure for the purpose of time-limited
endorsement and that the MAP recommend to HHS that these measures initially
only be used in confidential feedback reports and not for accountability
purposes.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program:
Hospital Value-Based Purchasing Program; MUC ID: X0351) |
- [Pre-workgroup meeting comment] Yes, under certain conditions -
payment includes anticoagulants drugs for the whole episode. (Submitted by:
Academy of Managed Care Pharmacy)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program:
Inpatient Quality Reporting Program ; MUC ID: X0351) |
- AGS supports this measure, but notes that misdiagnosis of UTI is
exceedingly common in frail elders, particularly nursing home residents. The
impact of misdiagnosis on this measure should be considered. For instance,
high rates of misdiagnosis may produce a less sick appearing population of
UTIs and/or may encourage providers to discharge these patients quickly
without looking for the true underlying condition. (Submitted by: American
Geriatrics Society)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues to
include only a 90-day "look-back period" for co-morbidities. This timeframe
should be aligned with other measures such as the mortality and readmission
measures that include 1 year. Additional analysis on the reliability and
validity of these measures is also needed before these measures are
conditionally endorsed for use within Medicareís physician-related value-based
payment provisions. It is difficult to evaluate whether the measures are
appropriate for adoption in light of this lack of information. Data on the
reliability of the measure specifications is needed and must be provided both
at the hospital and physician level. In addition and perhaps more
importantly, the validity of these measures must be demonstrated prior to
implementation in any pay-for-reporting or -performance program. While the
conditions may have presented as a higher proportion of Medicare patients, it
is unknown whether an individual hospital's sample size for some of these
conditions would be adequate to demonstrate clinically meaningful differences.
This concern only increases when considering implementing these measures at
the physician level. Finally, continuing to include cost of care measures in
the absence of accompanying quality measures addressing the same clinical
condition is contrary to NQF recommendations and the intent of the VBPM
program. We note that CMS withdrew many of these episode-based payment
measures from consideration in the Hospital Value-based Payment Program but
information on why is not provided. Applying these measures to physicians
without adequate review and testing would have significant negative unintended
consequences, particularly if they are not recommended for use in the level of
analysis for which they were developed.(Submitted by: American Medical
Association)
- We do not support this measure for adoption in the IQR program. Clinical
management for urinary tract infections, cellulitis, and gastrointestinal
hemorrhage can vary based on the array of underlying illnesses and other
factors that contribute to a patientís response to treatment. Therefore, the
payment per episode for these conditions could also vary greatly. A publicly
reported standard metric would not offer a clear understanding of differences
in quality of care based on payment by episode.(Submitted by: Greater New York
Hospital Association)
- Premier believe it is useful to explore differences in resource
utilization for certain, well understood, elective procedures that benefit
from adherence to a standardized process. Certain conditions like hip and
knee replacement meet those conditions. These three conditions mentioned
above, however, represent a potentially heterogeneous set of patients for
which there are varying possibilities for the degree of standardization of
care. For the most part, these are acute conditions, not necessarily subject
to standardization and therefore it is not clear at all whether variation in
the cost for these conditions is clinically justified or not. Secondly,
Premier feels that the most appropriate costs for each of these conditions is
0. That is, either the condition itself or the resulting hospitalization is
largely avoidable. This means that institutions which do an exceptionally
good job of keeping these patients out of the hospital, and therefore admit
the sickest of the sick, will now paradoxically be found wanting, as the cost
for this very special case population is likely to be higher. Premier does
not feel it makes sense to examine variation in costs for episodes that are
likely to be heterogeneous clinically, and for which a substantial portion
(outpatient) of the population is excluded. (Submitted by: Premier,
Inc.)
| (Program:
Value-Based Payment Modifier; MUC ID: X0351) |
- This measure was considered for inclusion in the Inpatient Quality
Reporting System, Hospital Value-Based Purchasing, the Physician Feedback
Program (QRURs), and the Physician Value-Based Payment Modifier. As such, this
measure is meant to reflect the total costs associated with caring for
patients with UTIs. However, without complementary quality measures, the
measure offers no tools or resources for how to improve, or in this case
decrease costs. SHM is also concerned that this measure is not appropriately
adjusted for variations in disease presentation and severity and variations in
the sociodemographic status of patients, which can often have significant
impacts on the course and costs associated with treatment. As providers who
will have this measure attributed to them in the Physician Value-Based Payment
Modifier, we stress that it is not appropriate at this time for inclusion in
pay for performance programs. Before its widespread use, we encourage the
development of a full set of complementary quality measures to be associated
with cost measures that will facilitate quality and performance
improvement.(Submitted by: Society of Hospital Medicine)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues to
include only a 90-day "look-back period" for co-morbidities. This timeframe
should be aligned with other measures such as the mortality and readmission
measures that include 1 year. Additional analysis on the reliability and
validity of these measures is also needed before these measures are
conditionally endorsed for use within Medicareís physician-related value-based
payment provisions. It is difficult to evaluate whether the measures are
appropriate for adoption in light of this lack of information. Data on the
reliability of the measure specifications is needed and must be provided both
at the hospital and physician level. In addition and perhaps more
importantly, the validity of these measures must be demonstrated prior to
implementation in any pay-for-reporting or -performance program. While the
conditions may have presented as a higher proportion of Medicare patients, it
is unknown whether an individual hospital's sample size for some of these
conditions would be adequate to demonstrate clinically meaningful differences.
This concern only increases when considering implementing these measures at
the physician level. Finally, continuing to include cost of care measures in
the absence of accompanying quality measures addressing the same clinical
condition is contrary to NQF recommendations and the intent of the VBPM
program. We note that CMS withdrew many of these episode-based payment
measures from consideration in the Hospital Value-based Payment Program but
information on why is not provided. Applying these measures to physicians
without adequate review and testing would have significant negative unintended
consequences, particularly if they are not recommended for use in the level of
analysis for which they were developed.(Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] We are encouraged that CMS has
included condition-specific episode of care measures on the MUC list but,
until thorough validity and reliability testing has been performed in settings
of prospective use, we will continue to have concerns over these efficiency
measures. Specific to the Cellulitis and UTI measures, IDSA was never
formally asked to contribute expert volunteers to these cost measure
development panels despite the topic relevancy to ID-care. As a result, IDSA
is unsure to what extent they were developed with appropriate/ relevant
clinical expertise. In our comment letter, we recommended that CMS gradually
incorporate episode-based and condition-specific cost measures into federal
quality programs by initially using this data only for confidential provider
feedback reports. We feel this will give CMS and providers time to evaluate
and potentially make changes to the accuracy, relevance, and format of these
measures prior to using them for accountability purposes. Therefore we ask
that NQF consider evaluating this measure for the purpose of time-limited
endorsement and that the MAP recommend to HHS that these measures initially
only be used in confidential feedback reports and not for accountability
purposes.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Physician
Feedback; MUC ID: X0352) |
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
| (Program: Hospital
Value-Based Purchasing Program; MUC ID: X0352) |
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X0352) |
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
| (Program: Value-Based
Payment Modifier; MUC ID: X0352) |
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
| (Program: Physician
Feedback; MUC ID: X0353) |
- NASS is in favor of processes to support improved information transfer and
communication between primary care providers and specialists and supports the
continued development of this measure.(Submitted by: North American Spine
Society)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- NASS is concerned about the narrow focus of the exclusion criteria and
agrees with the recommendation to include cancer/tumor as an exclusion. In an
effort to better homogenize the patient population for this measure, NASS also
recommends adding trauma and infection to exclusion criteria so that these
cases are not compared against elective cases. In addition to basic risk
adjustment methodologies for this measure, NASS also recommends that the
measure be stratified by the number of fusion levels performed and the area
where the fusion was perfumed (cervical, thoracic, lumbar). If the measure is
unable to be stratified by the exact number of fusions performed, NASS
recommends that the number of fusions are stratified in groupings, such as 1-2
levels, 3-5 levels, 6-9 levels or more than 10 levels. The indications for,
surgical timing and postoperative care required for fusions vary widely and
the associated costs are heavily influenced by a variety of factors, including
co-morbidities, number of fusion levels performed and region of the spine.
Thus, for comparison purposes, this level of granularity is necessary when
evaluating each fusion/refusion episode of care. This measure may ultimately
be used to compare the cost-efficiency of fusion episodes. This measure
directly impacts NASSí membership, and we cannot be supportive of this measure
until the issues discussed above are resolved.(Submitted by: North American
Spine Society)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X0353) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- NASS is in favor of processes to support improved information transfer and
communication between primary care providers and specialists and supports the
continued development of this measure.(Submitted by: North American Spine
Society)
- NASS is concerned about the narrow focus of the exclusion criteria and
agrees with the recommendation to include cancer/tumor as an exclusion. In an
effort to better homogenize the patient population for this measure, NASS also
recommends adding trauma and infection to exclusion criteria so that these
cases are not compared against elective cases. In addition to basic risk
adjustment methodologies for this measure, NASS also recommends that the
measure be stratified by the number of fusion levels performed and the area
where the fusion was perfumed (cervical, thoracic, lumbar). If the measure is
unable to be stratified by the exact number of fusions performed, NASS
recommends that the number of fusions are stratified in groupings, such as 1-2
levels, 3-5 levels, 6-9 levels or more than 10 levels. The indications for,
surgical timing and postoperative care required for fusions vary widely and
the associated costs are heavily influenced by a variety of factors, including
co-morbidities, number of fusion levels performed and region of the spine.
Thus, for comparison purposes, this level of granularity is necessary when
evaluating each fusion/refusion episode of care. This measure may ultimately
be used to compare the cost-efficiency of fusion episodes. This measure
directly impacts NASSí membership, and we cannot be supportive of this measure
until the issues discussed above are resolved.(Submitted by: North American
Spine Society)
- Comment 1 of 2 This measure, under consideration for the Hospital IQR,
constructs a ìclinically coherentî 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. The episode is 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 measure
assesses the cost of services initiated during an episode that spans the
period immediately prior to, during, and following a patientís hospital stay.
It attributes Medicare Part A and B payments for services that are clinically
related to the spine fusion/refusion to the hospital or the physician group
primarily responsible for the beneficiaryís care during the index hospital
stay. The AANS and CNS have expressed its opposition to this measure during
previous rulemaking periods. While we support efforts to transition to more
clinically focused episode-based cost measures, we continue to oppose this
measure, in its current format, for the following reasons: ï By including
post-acute care costs, the measure captures a much better global appreciation
of the cost of care, but also skews the results due to greater impact of
patient comorbidities, case severity, and other patient factors. For example,
the indexed hospital would be held accountable for the most expensive aspect
of the episode, which is typically inpatient rehabilitation, despite these
costs being outside its control. At the same time, in an effort to incentivize
more efficiently managed referrals to inpatient rehabilitation, this measure
could unintentionally create a perverse incentive for providers not to use
inpatient rehabilitation when it is truly appropriate, which could then lead
to greater spending and poorer quality care. In general, the benefits of the
inpatient rehabilitation stay are often not realized for months and may be
challenging to quantify.(Submitted by: American Association of Neurological
Surgeons/Congress of Neurological Surgeons)
- Comment 2 of 2 ï This measure could adversely affect facilities that have
a high percentage of patients that need rehabilitation (e.g., spinal cord
injury centers). ï CMS should, at this point in time, only use episode-based
cost measures for procedures that are fairly straightforward in terms of
indications and that have less variation in treatment options (e.g., total
knee or hip arthroplasty). The variation in what can be done appropriately
within the lumbar spine is relatively expansive. To put it into perspective,
TKAs and THAs deal with a single joint. At each lumbar level, there are 3
joints and 5 lumbar levels, which results in a total of 15 separate joints
that are treatable by anterior, posterior, lateral, or any combination of the
above. ï Similarly, using a one-size-fits-all MS-DRG trigger will result in
very poor data since the breadth of treatments within that DRG is too broad. A
previous analysis of this data indicated that standard deviations in the
lumbar fusion cases are higher than in any of the other categories. ï When
this measure was under consideration for the Hospital IQR, the number of CPT
codes included in the lumbar spine segment were so extensive that they
essentially covered all thoracolumbar spine procedures. This is going to muddy
the data. For example, a facility that routinely performs single level fusions
in patients that go home POD 3 could be directly compared to a facility that
routinely performs osteotomies and 10-level thoracolumbar reconstructive
procedures where the patients are in the ICU for 2 days and are discharged to
inpatient rehab POD 8, with the inpatient rehab counting against the second
facility. As presently constructed, this measure will simply identify
facilities that do more complex spine reconstructions, not facilities that
provide inefficient or low-value care.(Submitted by: American Association of
Neurological Surgeons/Congress of Neurological Surgeons)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly ifthey are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
| (Program: Value-Based
Payment Modifier; MUC ID: X0353) |
- NASS is in favor of processes to support improved information transfer and
communication between primary care providers and specialists and supports the
continued development of this measure.(Submitted by: North American Spine
Society)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- NASS is concerned about the narrow focus of the exclusion criteria and
agrees with the recommendation to include cancer/tumor as an exclusion. In an
effort to better homogenize the patient population for this measure, NASS also
recommends adding trauma and infection to exclusion criteria so that these
cases are not compared against elective cases. In addition to basic risk
adjustment methodologies for this measure, NASS also recommends that the
measure be stratified by the number of fusion levels performed and the area
where the fusion was perfumed (cervical, thoracic, lumbar). If the measure is
unable to be stratified by the exact number of fusions performed, NASS
recommends that the number of fusions are stratified in groupings, such as 1-2
levels, 3-5 levels, 6-9 levels or more than 10 levels. The indications for,
surgical timing and postoperative care required for fusions vary widely and
the associated costs are heavily influenced by a variety of factors, including
co-morbidities, number of fusion levels performed and region of the spine.
Thus, for comparison purposes, this level of granularity is necessary when
evaluating each fusion/refusion episode of care. This measure may ultimately
be used to compare the cost-efficiency of fusion episodes. This measure
directly impacts NASSí membership, and we cannot be supportive of this measure
until the issues discussed above are resolved.(Submitted by: North American
Spine Society)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Physician Feedback; MUC
ID: X0354) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] We are encouraged that CMS has
included condition-specific episode of care measures on the MUC list but,
until thorough validity and reliability testing has been performed in settings
of prospective use, we will continue to have concerns over these efficiency
measures. Specific to the Cellulitis and UTI measures, IDSA was never
formally asked to contribute expert volunteers to these cost measure
development panels despite the topic relevancy to ID-care. As a result, IDSA
is unsure to what extent they were developed with appropriate/ relevant
clinical expertise. In our comment letter, we recommended that CMS gradually
incorporate episode-based and condition-specific cost measures into federal
quality programs by initially using this data only for confidential provider
feedback reports. We feel this will give CMS and providers time to evaluate
and potentially make changes to the accuracy, relevance, and format of these
measures prior to using them for accountability purposes. Therefore we ask
that NQF consider evaluating this measure for the purpose of time-limited
endorsement and that the MAP recommend to HHS that these measures initially
only be used in confidential feedback reports and not for accountability
purposes.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X0354) |
- We do not support this measure for adoption in the IQR program. Clinical
management for urinary tract infections, cellulitis, and gastrointestinal
hemorrhage can vary based on the array of underlying illnesses and other
factors that contribute to a patientís response to treatment. Therefore, the
payment per episode for these conditions could also vary greatly. A publicly
reported standard metric would not offer a clear understanding of differences
in quality of care based on payment by episode.(Submitted by: Greater New York
Hospital Association)
- Premier believe it is useful to explore differences in resource
utilization for certain, well understood, elective procedures that benefit
from adherence to a standardized process. Certain conditions like hip and
knee replacement meet those conditions. These three conditions mentioned
above, however, represent a potentially heterogeneous set of patients for
which there are varying possibilities for the degree of standardization of
care. For the most part, these are acute conditions, not necessarily subject
to standardization and therefore it is not clear at all whether variation in
the cost for these conditions is clinically justified or not. Secondly,
Premier feels that the most appropriate costs for each of these conditions is
0. That is, either the condition itself or the resulting hospitalization is
largely avoidable. This means that institutions which do an exceptionally
good job of keeping these patients out of the hospital, and therefore admit
the sickest of the sick, will now paradoxically be found wanting, as the cost
for this very special case population is likely to be higher. Premier does
not feel it makes sense to examine variation in costs for episodes that are
likely to be heterogeneous clinically, and for which a substantial portion
(outpatient) of the population is excluded. (Submitted by: Premier,
Inc.)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
| (Program: Value-Based Payment
Modifier; MUC ID: X0354) |
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- This measure was considered for inclusion in the Inpatient Quality
Reporting System, Hospital Value-Based Purchasing, the Physician Feedback
Program (QRURs), and the Physician Value-Based Payment Modifier. As such, this
measure is meant to reflect the total costs associated with caring for
patients with cellulitis. However, without complementary quality measures, the
measure offers no tools or resources for how to improve, or in this case
decrease costs. SHM is also concerned that this measure is not appropriately
adjusted for variations in disease presentation and severity and variations in
the sociodemographic status of patients, which can often have significant
impacts on the course and costs associated with treatment. As providers who
will have this measure attributed to them in the Physician Value-Based Payment
Modifier, we stress that it is not appropriate at this time for inclusion in
pay for performance programs. Before its widespread use, we encourage the
development of a full set of complementary quality measures to be associated
with cost measures that will facilitate quality and performance
improvement.(Submitted by: Society of Hospital Medicine)
- [Pre-workgroup meeting comment] We are encouraged that CMS has
included condition-specific episode of care measures on the MUC list but,
until thorough validity and reliability testing has been performed in settings
of prospective use, we will continue to have concerns over these efficiency
measures. Specific to the Cellulitis and UTI measures, IDSA was never
formally asked to contribute expert volunteers to these cost measure
development panels despite the topic relevancy to ID-care. As a result, IDSA
is unsure to what extent they were developed with appropriate/ relevant
clinical expertise. In our comment letter, we recommended that CMS gradually
incorporate episode-based and condition-specific cost measures into federal
quality programs by initially using this data only for confidential provider
feedback reports. We feel this will give CMS and providers time to evaluate
and potentially make changes to the accuracy, relevance, and format of these
measures prior to using them for accountability purposes. Therefore we ask
that NQF consider evaluating this measure for the purpose of time-limited
endorsement and that the MAP recommend to HHS that these measures initially
only be used in confidential feedback reports and not for accountability
purposes.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program:
Physician Feedback; MUC ID: X0355) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Institute for Patient Safety and Quality)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program:
Inpatient Quality Reporting Program ; MUC ID: X0355) |
- AGS believes that more evaluation should be made to identify the
unintended consequences of this measurement strategy such as resistance to
performing necessary diagnostic procedures as an inpatient. As many procedures
have already been shifted to the outpatient setting, we would imagine
resistance to any inpatient procedures would grow. For frail elders in
particular, some procedures are hard to tolerate as an outpatient. (Submitted
by: American Geriatrics Society)
- We do not support this measure for adoption in the IQR program. Clinical
management for urinary tract infections, cellulitis, and gastrointestinal
hemorrhage can vary based on the array of underlying illnesses and other
factors that contribute to a patientís response to treatment. Therefore, the
payment per episode for these conditions could also vary greatly. A publicly
reported standard metric would not offer a clear understanding of differences
in quality of care based on payment by episode.(Submitted by: Greater New York
Hospital Association)
- Premier believe it is useful to explore differences in resource
utilization for certain, well understood, elective procedures that benefit
from adherence to a standardized process. Certain conditions like hip and
knee replacement meet those conditions. These three conditions mentioned
above, however, represent a potentially heterogeneous set of patients for
which there are varying possibilities for the degree of standardization of
care. For the most part, these are acute conditions, not necessarily subject
to standardization and therefore it is not clear at all whether variation in
the cost for these conditions is clinically justified or not. Secondly,
Premier feels that the most appropriate costs for each of these conditions is
0. That is, either the condition itself or the resulting hospitalization is
largely avoidable. This means that institutions which do an exceptionally
good job of keeping these patients out of the hospital, and therefore admit
the sickest of the sick, will now paradoxically be found wanting, as the cost
for this very special case population is likely to be higher. Premier does
not feel it makes sense to examine variation in costs for episodes that are
likely to be heterogeneous clinically, and for which a substantial portion
(outpatient) of the population is excluded. (Submitted by: Premier,
Inc.)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly if they are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
| (Program:
Value-Based Payment Modifier; MUC ID: X0355) |
- This measure was considered for inclusion in the Inpatient Quality
Reporting System, Hospital Value-Based Purchasing, the Physician Feedback
Program (QRURs), and the Physician Value-Based Payment Modifier. As such, this
measure is meant to reflect the total costs associated with caring for
patients with GI hemorrhage. However, without complementary quality measures,
the measure offers no tools or resources for how to improve, or in this case
decrease costs. SHM is also concerned that this measure is not appropriately
adjusted for variations in disease presentation and severity and variations in
the sociodemographic status of patients, which can often have significant
impacts on the course and costs associated with treatment. As providers who
will have this measure attributed to them in the Physician Value-Based Payment
Modifier, we stress that it is not appropriate at this time for inclusion in
pay for performance programs. Before its widespread use, we encourage the
development of a full set of complementary quality measures to be associated
with cost measures that will facilitate quality and performance
improvement.(Submitted by: Society of Hospital Medicine)
- The AMA has a number of concerns and questions that preclude our support
for continued development of these measures without further information and
assurances from CMS. We have a long-standing and frequently stated objection
to CMSís tendency to extend measures created for hospitals to physicians.
First, although there are some questions about the history of these measures,
it is our understanding that they were developed specifically to measure
hospital performance and therefore do not comply with the AMAís and the MAPís
goal of implementing measures only for the level of measurement for which it
was originally developed. This presents a number of problems. For example,
while each measure captures care provided 30days following discharge with a
trigger event, the developers did not address how attribution to physicians
would occur. In addition, each condition was selected based on the proportion
of Medicare payments it encompassed when reviewing all possible conditions or
procedures addressed by hospitals. However, It is doubtful that the total
payment for several of these conditions would rank as high for physicians as
they did for hospitals. We are also concerned that this measure continues
to include only a 90-day "look-back period" for co-morbidities. This
timeframe should be aligned with other measures such as the mortality and
readmission measures that include 1 year. Additional analysis on the
reliability and validity of these measures is also needed before these
measures are conditionally endorsed for use within Medicareís
physician-related value-based payment provisions. It is difficult to evaluate
whether the measures are appropriate for adoption in light of this lack of
information. Data on the reliability of the measure specifications is needed
and must be provided both at the hospital and physician level. In addition
and perhaps more importantly, the validity of these measures must be
demonstrated prior to implementation in any pay-for-reporting or -performance
program. While the conditions may have presented as a higher proportion of
Medicare patients, it is unknown whether an individual hospital's sample size
for some of these conditions would be adequate to demonstrate clinically
meaningful differences. This concern only increases when considering
implementing these measures at the physician level. Finally, continuing to
include cost of care measures in the absence of accompanying quality measures
addressing the same clinical condition is contrary to NQF recommendations and
the intent of the VBPM program. We note that CMS withdrew many of these
episode-based payment measures from consideration in the Hospital Value-based
Payment Program but information on why is not provided. Applying these
measures to physicians without adequate review and testing would have
significant negative unintended consequences, particularly ifthey are not
recommended for use in the level of analysis for which they were
developed.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Physician
Feedback; MUC ID: X0356) |
- [Pre-workgroup meeting comment] Yes, under certain conditions -
payment includes anticoagulants drugs for the whole episode. (Submitted by:
Academy of Managed Care Pharmacy)
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program: Hospital
Value-Based Purchasing Program; MUC ID: X0356) |
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X0356) |
- [Pre-workgroup meeting comment] Yes, under certain conditions -
payment includes anticoagulants drugs for the whole episode. (Submitted by:
Academy of Managed Care Pharmacy)
| (Program: Value-Based
Payment Modifier; MUC ID: X0356) |
- [Pre-workgroup meeting comment] Yes, under certain conditions -
payment includes anticoagulants drugs for the whole episode. (Submitted by:
Academy of Managed Care Pharmacy)
- [Pre-workgroup meeting comment] We oppose the use of this measure
in the programs identified by CMS.(Submitted by: AdvaMed)
- [Pre-workgroup meeting comment] While it is our understanding that
these episode groupers were tested in the supplemental QRURs, we think that
until the contractor report on these QRURs is available, MAP should reserve
judgment on whether they should be recommended or not. (Submitted by:
American Medical Association)
| (Program:
Inpatient Quality Reporting Program ; MUC ID: X1234) |
- In regards to the measure titled X1234: Timely evaluation of high-risk
individuals in the emergency department, ACEP strongly agrees with the MAPís
preliminary decision to encourage continued development.(Submitted by:
American College of Emergency Physicians Quality & Performance
Committee)
- GNYHA does not support this measure for the IQR or e-CQM program because
the measure has not yet been validated as an electronic measure. In addition,
to account for patient severity, Measure X1234 captures the emergency
department (ED) triage level assigned when a patient presents. Because there
is no standardized set of guidelines for assigning ED triage levels, hospitals
have developed and rely on their own internal guidelines to assign the
appropriate severity level. The lack of a consistent, standardized approach
for categorizing patients for ED triage is a significant shortcoming for this
measure and it should not be supported by the MAP. (Submitted by: Greater New
York Hospital Association)
| (Program:
Medicare and Medicaid EHR Incentive Program for Hospitals and Critical
Access Hospitals (CAHs) ; MUC ID: X1234) |
- In regards to the measure titled X1234: Timely evaluation of high-risk
individuals in the emergency department, ACEP strongly agrees with the MAPís
preliminary decision to encourage continued development.(Submitted by:
American College of Emergency Physicians Quality & Performance
Committee)
- GNYHA does not support this measure for the IQR or e-CQM program because
the measure has not yet been validated as an electronic measure. In addition,
to account for patient severity, Measure X1234 captures the emergency
department (ED) triage level assigned when a patient presents. Because there
is no standardized set of guidelines for assigning ED triage levels, hospitals
have developed and rely on their own internal guidelines to assign the
appropriate severity level. The lack of a consistent, standardized approach
for categorizing patients for ED triage is a significant shortcoming for this
measure and it should not be supported by the MAP. (Submitted by: Greater New
York Hospital Association)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X1970) |
- We appreciate MAPís consideration of this electronically specified measure
addressing a high impact area of health care quality improvement. However, we
urge the Coordinating Committee to reconsider X1970 as a fully developed and
tested measure for potential inclusion in the Inpatient Quality Reporting
Program. Notably, the paper version of this measure was endorsed by NQF in
2008 and subsequently re-endorsed in 2012. We understand that The Joint
Commission, the steward of this measure, considers this measure to be fully
developed and tested as an electronic clinical quality measure. Therefore, we
request that the Coordinating Committee reconsider this e-measure and follow
the Workgroupís approach to the re-categorization of measures initially deemed
ìunder developmentî in light of new information received. Furthermore, C-P
Alliance would like to emphasize the importance of quality measurement and
public reporting in driving improvements in maternal and newborn care. This is
a population health issue, which impacts 85 percent of women who give birth
once or more during their lifetime. Within hospitals, the combined care of
childbearing women and newborns far exceeds the volume and total cost of care
for any other Major Diagnostic Group, with considerable implications for
Medicaid, employer purchasers, and commercial insurers. This particular
measure addressing cesarean section, the most common operating room procedure
in the country, has the potential for far-reaching impact on health outcomes
of women and babies and maternity care costs. (Submitted by:
Consumer-Purchaser Alliance)
- The Joint Commission appreciates the interest in this measures. Please be
aware that this measure has been electronically specified and was posted on
the CMS website for public comment between June and July 2014. The measure was
not taken to NQF for endorsement, as CMS states that endorsement for the
manually specified measure also accounts for the electronically specified
version (this was clarified in response to comments on the 2015 IPPS final
rule) In summary, the measure is fully specified as an eCQM, and is
considered endorsed under CMSís definition (Submitted by: The Joint
Commission)
- [Pre-workgroup meeting comment] The proposed measure is based on
flawed science and will yield meaningless results due to the following
reasons: First is that the measure includes women who have contraindications
for vaginal birth such as placenta previa, fetal distress prior to labor and
medical contraindications for labor. An increase or decrease in women with
these diagnoses can significantly affect the outcome of the measure resulting
in an inaccurate measure of the effect that the obstetrical care provider has
on the risk for a cesarean birth. Even one or two additional cesarean births
due to these diagnoses can significantly affect the measure as is illustrated
in the third concern below. Second is that the measure assumes that all
nulliparous women with a term single fetus in the vertex position (NTSV) have
the same risk for cesarean birth after adjusting for age. However, in
addition to maternal age, there are other physical characteristics of the
mother and her baby that have been previously proven to significantly affect
the risk for a cesarean birth. These include newborn weight, maternal initial
body mass index, maternal height, maternal weight gain and gestational age.
In addition, induction of labor has also been previously proven to
significantly increase the risk for a cesarean birth. Failure to provide any
risk adjustment for all of these previously proven risk factors will result in
a misleading measure for obstetrical care providers. For example, obstetrical
care providers who care for women with gestational diabetes may have patients
who are heavier, carrying bigger babies, have gained more weight and will be
more likely to have a medical indication for induction of labor. These
providers, under this measure, will be assigned a measure that is worse than
it should be because the measure does not provide any risk adjustment for
these previously proven risk factors. THIRD AND MOST IMPORTANT is a major
flaw found in the direct standardization technique being used to create the
risk adjustment for age. The direct standardization technique used in the
measure is based on the work of Main, et al from 2006. The flaw in the direct
standardization technique is illustrated by the sample hospital in their
study. The sample hospital in their study had approximately 18,000 births over
a three year period in order to create a target population of 7,068
nulliparous term singleton vertex (NTSV) births of which only 68 were in the
15 to 19 year old age group. This age group is assigned a weight of 21% in
the direct standardization. This means that even though the sample hospital
only had 1% of their births in the 15 to 19 year old age group this age group
will be used to assign 21% of their cesarean birth measure. A small change in
the number of cesarean births within that age group will result in a large
change in their cesarean birth measure. Even with 6,000 total births each year
the sample hospital will only have two patients per month and six patients per
quarter accounting for 21% of their cesarean birth measure. This will make it
very difficult for the sample hospital to obtain consistent results and this
problem would only be magnified if the hospital had fewer than 6,000 births
per year. If a hospital has the same age distribution of NTSV patients as the
sample hospital in the study, analysis will show that one additional cesarean
birth in the 15 to 19 year old age group per 1,000 total births this year than
last year will increase their cesarean birth measure by five percentage
points. This flaw makes this measure meaningless for hospitals that have a
similar age distribution as the sample hospital in the study. Lastly, the
goal of a cesarean birth measure is to measure the risk applied by the
obstetrical care provider. The accuracy of a cesarean birth measure is best
proven by its ability to predict future outcomes. This measure does not
provide this type of validation. A measure that cannot accurately predict
future outcomes is merely an educated guess of the risk applied and not truly
a measure. Therefore, this measure may do more harm than good.(Submitted by:
Birthrisk.com, LLC.)
- [Pre-workgroup meeting comment] My (layperson's) understanding is
that some c-sections performed on this population are in fact justified. Such
c-sections should be excluded from inferences about inappropriate c-sections
presumably intended to be measured by X1970. Such c-sections should be
measurable as a subset of the proposed measure. I believe the key
differentiation is "non-labor" c-sections, i.e. medically indicated, no labor
occurs. C-sections performed after commencement of labor, in contrast, may be
done for no reason other than preference of physician and/or patient. Pl
consult the experts addressing c-section rates for strategies to distinguish
medically necessary from not-medically-necessary for the population targeted
in the measure. The rationale for the measure, pp.253-54, does not address
this problem. Thanks. (Submitted by: Health Care Planning and
Policy)
| (Program: Medicare and
Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals
(CAHs) ; MUC ID: X1970) |
- The Joint Commission appreciates the interest in this measure. Please be
aware that this measure (PC-02) has been electronically specified and was
posted on the CMS website for public comment between June and July 2014. The
measure was not taken to NQF for endorsement, as CMS states that endorsement
for the manually specified measure also accounts for the electronically
specified version (this was clarified in response to comments on the 2015 IPPS
final rule) (Submitted by: The Joint Commission)
- [Pre-workgroup meeting comment] The proposed measure is based on
flawed science and will yield meaningless results due to the following
reasons: First is that the measure includes women who have contraindications
for vaginal birth such as placenta previa, fetal distress prior to labor and
medical contraindications for labor. An increase or decrease in women with
these diagnoses can significantly affect the outcome of the measure resulting
in an inaccurate measure of the effect that the obstetrical care provider has
on the risk for a cesarean birth. Even one or two additional cesarean births
due to these diagnoses can significantly affect the measure as is illustrated
in the third concern below. Second is that the measure assumes that all
nulliparous women with a term single fetus in the vertex position (NTSV) have
the same risk for cesarean birth after adjusting for age. However, in
addition to maternal age, there are other physical characteristics of the
mother and her baby that have been previously proven to significantly affect
the risk for a cesarean birth. These include newborn weight, maternal initial
body mass index, maternal height, maternal weight gain and gestational age.
In addition, induction of labor has also been previously proven to
significantly increase the risk for a cesarean birth. Failure to provide any
risk adjustment for all of these previously proven risk factors will result in
a misleading measure for obstetrical care providers. For example, obstetrical
care providers who care for women with gestational diabetes may have patients
who are heavier, carrying bigger babies, have gained more weight and will be
more likely to have a medical indication for induction of labor. These
providers, under this measure, will be assigned a measure that is worse than
it should be because the measure does not provide any risk adjustment for
these previously proven risk factors. THIRD AND MOST IMPORTANT is a major
flaw found in the direct standardization technique being used to create the
risk adjustment for age. The direct standardization technique used in the
measure is based on the work of Main, et al from 2006. The flaw in the direct
standardization technique is illustrated by the sample hospital in their
study. The sample hospital in their study had approximately 18,000 births over
a three year period in order to create a target population of 7,068
nulliparous term singleton vertex (NTSV) births of which only 68 were in the
15 to 19 year old age group. This age group is assigned a weight of 21% in
the direct standardization. This means that even though the sample hospital
only had 1% of their births in the 15 to 19 year old age group this age group
will be used to assign 21% of their cesarean birth measure. A small change in
the number of cesarean births within that age group will result in a large
change in their cesarean birth measure. Even with 6,000 total births each year
the sample hospital will only have two patients per month and six patients per
quarter accounting for 21% of their cesarean birth measure. This will make it
very difficult for the sample hospital to obtain consistent results and this
problem would only be magnified if the hospital had fewer than 6,000 births
per year. If a hospital has the same age distribution of NTSV patients as the
sample hospital in the study, analysis will show that one additional cesarean
birth in the 15 to 19 year old age group per 1,000 total births this year than
last year will increase their cesarean birth measure by five percentage
points. This flaw makes this measure meaningless for hospitals that have a
similar age distribution as the sample hospital in the study. Lastly, the
goal of a cesarean birth measure is to measure the risk applied by the
obstetrical care provider. The accuracy of a cesarean birth measure is best
proven by its ability to predict future outcomes. This measure does not
provide this type of validation. A measure that cannot accurately predict
future outcomes is merely an educated guess of the risk applied and not truly
a measure. Therefore, this measure may do more harm than good. (Submitted by:
Birthrisk.com, LLC.)
| (Program: End-Stage Renal
Disease Quality Incentive Program ; MUC ID: X2051) |
- KCP supports the PAC/LTC Workgroupís recommendation for conditional
support for X2051, pending NQF endorsement and also subject to the public
availability of testing results. All three adequacy measures (X3717, X3718,
and X2051) are composites. Combining measures into a composite format can
materially alter the properties intrinsic to the component measures; even
though the individual measures have been tested, this does not negate the need
for the composite measures to be tested. Additionally, although we offer
conditional support for X2051, KCP urges that CMS continue to work with the
community on assessing pediatric-specific quality. We acknowledge and
generally support the MAPís view on the importance of parsimony, but if CMS
were to deploy only X2051 in the QIP as the measure for adequacy,
pediatric-specific quality would effectively be masked by the overwhelming
contribution of the numbers of adult patients.(Submitted by: Kidney Care
Partners (KCP))
- The updated KDOQI draft hemodialysis adequacy guidelines are currently
undergoing internal review by NKFís Scientific Advisory Board. Once that
review is complete, in early February, the draft guidelines will be available
for public review and comment (interested parties can register now to review
the guidelines at
https://www.kidney.org/professionals/KDOQI/guidelines_commentaries). Currently
these proposed adequacy measures are in line with those draft guidelines as
well as the 2006 KDOQI hemodialysis and peritoneal dialysis adequacy
guidelines currently in place. However, we point out that these are minimum
standards for achievements and higher targets may be appropriate, particularly
for patients who struggle with fluid management.(Submitted by: National Kidney
Foundation)
- ASN supports this measure in concept, and agrees that this measure should
receive conditional support from NQF. As stated in our previous comment
letter, ASN believes this measure should not use all three scores, but rather
two separate scores for PD and HD or the composite. Using only the composite
could help smaller home dialysis programs ñ as they could combine their PD and
HHD populations and possibly avoid falling below the threshold because of
small numbers. Further evaluation is likely needed to determine the precise
composition of the composite measure and the interplay among this measure and
the existing dose of dialysis measures.(Submitted by: American Society of
Nephrology (ASN))
- [Pre-workgroup meeting comment] ASN supports this measure in
concept, however would suggest that NQF does not use all three scores, but
rather two separate scores for PD and HD or the composite. Using only the
composite could help smaller home dialysis programs ñ as they could combine
their PD and HHD populations and possibly avoid falling below the threshold
because of small numbers(Submitted by: American Society of
Nephrology)
| (Program:
Medicare Shared Savings Program; MUC ID: X2147) |
- We support the MAP recommendation of ìDo Not Supportî for this measure.
Accountable Care Organizations are already incentivized to control
costs(Submitted by: American Medical Association)
| (Program: Medicare Shared Savings Program; MUC ID: X3053)
|
- The ACR supports measurement of functional status in osteoarthritis and
believe this is an important area and promising measure concept. However, we
are concerned that this measure is beyond what is currently feasible in
practice and do not believe the systems are in place in most practices to
support this measure. (Submitted by: American College of
Rheumatology)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3053) |
- The ACR supports measurement of functional status in osteoarthritis and
believe this is an important area and promising measure concept. However, we
are concerned that this measure is beyond what is currently feasible in
practice and do not believe the systems are in place in most practices to
support this measure. (Submitted by: American College of
Rheumatology)
- Many of the measures require reassessments and therefore will generate
multiple encounters to calculate the measure (for example, x3053, Functional
Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
(encourage continued development)). CMS should test these measures for
reliability and validity given their complexity prior to implementation in any
pay-for-reporting or performance program. In addition, the measures do not
provide any guidance around the number needed to define performance and
therefore could have the unintended consequences of increased and potentially
unnecessary office visits. (Submitted by: American Medical
Association)
- Additionally, the denominator must include that the patient must have had
two visits in the measurement period for which the dx was captured. Otherwise,
how would the two values be determined?(Submitted by: Armstrong Instititue for
Patient Safety and Quality)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3053)
|
- The ACR supports measurement of functional status in osteoarthritis and
believe this is an important area and promising measure concept. However, we
are concerned that this measure is beyond what is currently feasible in
practice and do not believe the systems are in place in most practices to
support this measure. (Submitted by: American College of
Rheumatology)
| (Program: Medicare Shared Savings Program; MUC ID:
X3274) |
- Amgen supports MUC X3274 ìAssessment for Psoriatic Arthritisî for
inclusion in the CMS quality programs for clinicians. Amgen supports
performance measures that encourage diagnosis and treatment of psoriasis and
psoriatic arthritis. Psoriasis is a systemic inflammatory disease of the skin
and is the most common autoimmune disease in US, affecting nearly 7.5 million
people (National Psoriasis Foundation). Up to thirty percent of those with
psoriasis can develop psoriatic arthritis, which causes joint swelling and
pain. With very few quality measures in the dermatologic space, both measures
address a significant measure gap. Both conditions can be debilitating and can
lead to permanent disability if left untreated, but fortunately respond to
various treatments, including systemic and biologic immunotherapy. Identifying
psoriatic arthritis in people with psoriasis can lead to improved therapy.
Evaluating clinical response to psoriasis medications can determine the most
effective treatment. This measure can also enhance quality of life in the
psoriasis population. We fully support this measures that highlights the
importance of screening for psoriatic arthritis. (Submitted by:
Amgen)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3274) |
- We support the inclusion of this important process measure of psoriasis
care. We note that the support is conditional on satisfactory testing at the
clinician level and submission to NQF for consideration for endorsement. The
AAD has begun testing psoriasis measures (including X3274 and X3726) and
anticipates seeking NQF endorsement in 2016. Screening for psoriasis is
critically important to the early diagnosis and treatment. Not only does early
diagnosis alleviate signs and symptoms of Psoriasis, but it also prevents
structural damage associated with advanced stages of the disease, thereby
maximizing quality of life. With the ability of TNF-alpha inhibitors and some
of the newer biologic medications to halt progression of the destructive
irreversible nature of psoriatic arthritis, early intervention is crucial to
psoriatic patients. The addition of this measure along with measure 3726
would allow more reporting on the care for psoriasis, the most prevalent
autoimmune disease in the U.S., affecting about 7.5 million Americans. For
dermatology care, PQRS has only a few measures, including only one measure
related to psoriasis. Adding dermatology-specific measures to PQRS will help
dermatologists continue to report successfully, avoid penalties for
under-reporting for programs such as PQRS and the Value Based Payment
Modifier, and more importantly, to contribute to the quality and performance
goals of CMS. (Submitted by: American Academy of Dermatology)
- Amgen supports MUC X3274 ìAssessment for Psoriatic Arthritisî for
inclusion in the CMS quality programs for clinicians. Amgen supports
performance measures that encourage diagnosis and treatment of psoriasis and
psoriatic arthritis. Psoriasis is a systemic inflammatory disease of the skin
and is the most common autoimmune disease in US, affecting nearly 7.5 million
people (National Psoriasis Foundation). Up to thirty percent of those with
psoriasis can develop psoriatic arthritis, which causes joint swelling and
pain. With very few quality measures in the dermatologic space, both measures
address a significant measure gap. Both conditions can be debilitating and can
lead to permanent disability if left untreated, but fortunately respond to
various treatments, including systemic and biologic immunotherapy. Identifying
psoriatic arthritis in people with psoriasis can lead to improved therapy.
Evaluating clinical response to psoriasis medications can determine the most
effective treatment. This measure can also enhance quality of life in the
psoriasis population. We fully support this measures that highlights the
importance of screening for psoriatic arthritis. (Submitted by:
Amgen)
- [Pre-workgroup meeting comment] Measure X3274 - Assessment for
Psoriatic Arthritis Comments: We support the inclusion of this important
process measure of psoriasis care. Screening for psoriatic arthritis is
critically important to early diagnosis and treatment of this underdiagnosed
and potentially debilitating disease. Not only does early diagnosis alleviate
signs and symptoms of psoriatic arthritis, but it also prevents structural
damage associated with advanced stages of the disease, thereby maximizing
quality of life. With the ability of TNF-alpha inhibitors and some of the
newer biologic medications to halt progression of the destructive irreversible
nature of psoriatic arthritis, early intervention is crucial to patients with
psoriatic arthritis. The addition of this measure along with measure 3726
would allow more reporting on the care for psoriasis, the most prevalent
autoimmune disease in the U.S., affecting about 7.5 million Americans. For
dermatology care, PQRS has only a few measures, including only one measure
related to psoriasis. Adding dermatology-specific measures to PQRS will help
dermatologists continue to report successfully, avoid penalties for
under-reporting for programs such as PQRS and the Value Based Payment
Modifier, and more importantly, to contribute to the quality and performance
goals of CMS. (Submitted by: American Academy of Dermatology)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3276) |
- [Pre-workgroup meeting comment] Measure X3726 - Clinical Response
to Oral Systemic or Biologic Medications Comments: We support the inclusion of
this important outcome measure of psoriasis care. This measure evaluates the
proportion of psoriasis patients receiving systemic or biologic therapy who
meet minimal physician- or patient-reported disease activity levels.
Additionally, this measure provides an opportunity to objectively and/or
subjectively assess the effectiveness of medications in a standardized fashion
and how they affect symptoms and /or improve patientsí quality of life. The
addition of this measure, along with measure X3274, would improve the care for
psoriasis, the most prevalent autoimmune disease in the U.S., affecting about
7.5 million Americans. For dermatology care, PQRS has only a few measures,
including only one measure related to psoriasis and no outcomes measures.
Adding this dermatology-specific outcome measure to PQRS will help
dermatologists continue to report successfully, avoid penalties for
under-reporting for programs such as PQRS and the Value Based Payment
Modifier, and more importantly, to contribute to the quality and performance
goals of CMS.(Submitted by: American Academy of Dermatology)
| (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X3280) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
| (Program: Medicare Shared Savings Program; MUC ID: X3283)
|
- This is a laudable measure but the intent will not be achieved if the
information contained in the referral comes across in a way that is not well
deciphered/incorporated into the EHR. Therefore, we do not support a measure
that pushes a provider to have to do something that still needs serious
technical refinements. For this to occur, ONC would have to tighten up the use
of CCDA. However, if FHIR communication is implemented widely within EHRs, we
will be in a better position to conduct semantic exchange. We also suggest
the measure be further refined by not designating the specific information
that must be exchanged just that exchange happens. The provider is best suited
to determine what information should be exchanged. FHIR allows for ìprofilesî
to be created that tell EHRs what is expected in the message on a case by case
basis. For instance, a hospital may have one referral profile that differs
from the primary care providers, but both systems could easily talk because
the method of understanding profiles is core to how FHIR is implemented. The
AMA-PCPI recently completed a performance improvement project related to the
ambulatory referral process and learned much about the benefits and challenges
of redesigning the ambulatory referral process. It would be advantageous for
CMS to consult with them before moving forward.(Submitted by: American Medical
Association)
- The ACS strongly supports the MAP Clinician Workgroupís recommendation of
ìencourage continued developmentî of this measure. This measure is broadly
applicable to providers, reportable across surgery, and poses an opportunity
for improved communication in post-operative care, especially if the 10- and
90- day global surgery codes are transitioned to 0-day global codes. ACS
recommends that continued development be prioritized by CMS and the National
Committee for Quality Assurance. (Submitted by: The American College of
Surgeons)
- [Pre-workgroup meeting comment] This is a laudable measure but the
intent will not be achieved if the information contained in the referral comes
across in a way that is not well deciphered/incorporated into the EHR.
Therefore, we do not support a measure that pushes a provider to have to do
something that still needs serious technical refinements. For this to occur,
ONC would have to tighten up the use of CCDA. However, if FHIR communication
is implemented widely within EHRs, we will be in a better position to conduct
semantic exchange. We also suggest the measure be further refined by not
designating the specific information that must be exchanged just that exchange
happens. The provider is best suited to determine what information should be
exchanged. FHIR allows for ìprofilesî to be created that tell EHRs what is
expected in the message on a case by case basis. For instance, a hospital may
have one referral profile that differs from the primary care providers, but
both systems could easily talk because the method of understanding profiles is
core to how FHIR is implemented. (Submitted by: American Medical
Association)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3283) |
- This is a laudable measure but the intent will not be achieved if the
information contained in the referral comes across in a way that is not well
deciphered/incorporated into the EHR. Therefore, we do not support a measure
that pushes a provider to have to do something that still needs serious
technical refinements. For this to occur, ONC would have to tighten up the use
of CCDA. However, if FHIR communication is implemented widely within EHRs, we
will be in a better position to conduct semantic exchange. The American
Medical Association-convened Physician Consortium for Performance Improvement
(PCPI) recently completed a performance improvement project related to the
ambulatory referral process and learned much about the benefits and challenges
of redesigning the ambulatory referral process. It would be advantageous for
CMS to consult with them before constructing this measure.(Submitted by:
American Medical Association)
- This opportunity should also be used to acknowledge that if a provider
exchanges documents with a certified HIE, they meet this. This should be on
both the primary care and specialty ends. (Submitted by: Armstrong Instititue
for Patient Safety and Quality)
- The ACS strongly supports the MAP Clinician Workgroupís recommendation of
ìencourage continued developmentî of this measure for the EHR Incentive
Program. This measure is broadly applicable to providers, reportable across
surgery, and poses an opportunity for improved communication in post-operative
care, especially if the 10- and 90- day global surgery codes are transitioned
to 0-day global codes. ACS recommends that continued development be
prioritized by CMS and the National Committee for Quality Assurance. This
measure is especially critical for surgical specialists who currently lack
relevant and meaningful measures in the EHR Incentive Program. (Submitted by:
The American College of Surgeons)
- [Pre-workgroup meeting comment] This is a laudable measure but the
intent will not be achieved if the information contained in the referral comes
across in a way that is not well deciphered/incorporated into the EHR.
Therefore, we do not support a measure that pushes a provider to have to do
something that still needs serious technical refinements. For this to occur,
ONC would have to tighten up the use of CCDA. However, if FHIR communication
is implemented widely within EHRs, we will be in a better position to conduct
semantic exchange. We also suggest the measure be further refined by not
designating the specific information that must be exchanged just that exchange
happens. The provider is best suited to determine what information should be
exchanged. FHIR allows for ìprofilesî to be created that tell EHRs what is
expected in the message on a case by case basis. For instance, a hospital may
have one referral profile that differs from the primary care providers, but
both systems could easily talk because the method of understanding profiles is
core to how FHIR is implemented. (Submitted by: American Medical
Association)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3283)
|
- This is a laudable measure but the intent will not be achieved if the
information contained in the referral comes across in a way that is not well
deciphered/incorporated into the EHR. Therefore, we do not support a measure
that pushes a provider to have to do something that still needs serious
technical refinements. For this to occur, ONC would have to tighten up the use
of CCDA. However, if FHIR communication is implemented widely within EHRs, we
will be in a better position to conduct semantic exchange. We also suggest
the measure be further refined by not designating the specific information
that must be exchanged just that exchange happens. The provider is best suited
to determine what information should be exchanged. FHIR allows for ìprofilesî
to be created that tell EHRs what is expected in the message on a case by case
basis. For instance, a hospital may have one referral profile that differs
from the primary care providers, but both systems could easily talk because
the method of understanding profiles is core to how FHIR is
implemented.(Submitted by: American Medical Association)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- The ACS strongly supports the MAP Clinician Workgroupís recommendation of
ìencourage continued developmentî of this measure. This measure is broadly
applicable to providers, reportable across surgery, and poses an opportunity
for improved communication in post-operative care, especially if the 10- and
90- day global surgery codes are transitioned to 0-day global codes. ACS
recommends that continued development be prioritized by CMS and the National
Committee for Quality Assurance. This measure is especially critical for
surgical specialists who currently lack relevant and meaningful measures in
the EHR Incentive Program.(Submitted by: The American College of
Surgeons)
- ASN does not support this process measure, and believes this measure would
be very difficult to track. Given the recent inclusion in the ESRD Final Rule
suggesting referrals be made from dialysis units for certain conditions, we
note that facilities currently lack the capacity for electronic transmission
of referrals through a common EMR.(Submitted by: American Society of
Nephrology (ASN))
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] This is a laudable measure but the
intent will not be achieved if the information contained in the referral comes
across in a way that is not well deciphered/incorporated into the EHR.
Therefore, we do not support a measure that pushes a provider to have to do
something that still needs serious technical refinements. For this to occur,
ONC would have to tighten up the use of CCDA. However, if FHIR communication
is implemented widely within EHRs, we will be in a better position to conduct
semantic exchange. We also suggest the measure be further refined by not
designating the specific information that must be exchanged just that exchange
happens. The provider is best suited to determine what information should be
exchanged. FHIR allows for ìprofilesî to be created that tell EHRs what is
expected in the message on a case by case basis. For instance, a hospital may
have one referral profile that differs from the primary care providers, but
both systems could easily talk because the method of understanding profiles is
core to how FHIR is implemented. (Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] This is a laudable measure but the
intent will not be achieved if the information contained in the referral comes
across in a way that is not well deciphered/incorporated into the EHR.
Therefore, we do not support a measure that pushes a provider to have to do
something that still needs serious technical refinements. For this to occur,
ONC would have to tighten up the use of CCDA. However, if FHIR communication
is implemented widely within EHRs, we will be in a better position to conduct
semantic exchange. We also suggest the measure be further refined by not
designating the specific information that must be exchanged just that exchange
happens. The provider is best suited to determine what information should be
exchanged. FHIR allows for ìprofilesî to be created that tell EHRs what is
expected in the message on a case by case basis. For instance, a hospital may
have one referral profile that differs from the primary care providers, but
both systems could easily talk because the method of understanding profiles is
core to how FHIR is implemented. (Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] ASN does not support this process
measure, and believes this measure would be very difficult to track. Given the
recent inclusion in the ESRD Final Rule suggesting referrals be made from
dialysis units for certain conditions, we note that facilities currently lack
the capacity for electronic transmission of referrals through a common
EMR.(Submitted by: American Society of Nephrology (ASN))
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3299) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- HIVMA strongly supports implementation and uptake of this
measure.(Submitted by: HIV Medicine Association)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3299) |
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program: Medicare Shared Savings Program; MUC ID: X3300)
|
- HIVMA strongly supports monitoring the outcomes of patients with HIV
infection who are enrolled in the Medicare Shared Savings Program. We support
the MAPís recommendation to develop rolled-up or composite measures for
specific conditions, including HIV/AIDS, with the involvement of HIV experts
including HIVMA members.(Submitted by: HIV Medicine
Association)
| (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: X3300) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- HIVMA strongly supports implementation and uptake of this
measure.(Submitted by: HIV Medicine Association)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3300) |
- HIVMA strongly supports implementation and uptake of this
measure.(Submitted by: HIV Medicine Association)
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program:
Medicare Shared Savings Program; MUC ID: X3302) |
- NASS is in favor of processes to support improved information transfer and
communication between primary care providers and specialists and supports the
continued development of this measure.(Submitted by: North American Spine
Society)
| (Program: Inpatient
Quality Reporting Program ; MUC ID: X3323) |
- 4. Proper medication dosing for people with impaired renal function is
paramount to avoiding kidney failure, acute kidney injury, cardiovascular
events and other adverse events for people with kidney disease. As such, NKF
supports: ï X3323 Adverse Drug Events: - Inappropriate Renal Dosing of
Anticoagulants Patients with chronic kidney disease are at an increased risk
of bleeding when using anticoagulants; they are also more likely to be
prescribed these medications as they are more susceptible to blood clots and
venous thromboembolism (VTE). It is important that proper dosing occur for
patients with impaired kidney function, including those on dialysis. While
NKF supports the measure, we believe hospital admissions of dialysis patients
should not be excluded. NKF also does not believe that admissions, for
observation only, should be excluded as we aware of incidences where dialysis
patients have been improperly kept in observation status for multiple days,
presumably as a strategy to avoid accountability for the patient in quality
measure programs. NKF also supports this measure because it creates a
stronger incentive for hospitals to test for CKD in people with known risk
factors (e.g. diabetes, hypertension, age over 60 and family history of kidney
failure) prior to prescribing an anticoagulant to avoid the adverse event.
CKD is widely under-diagnosed even among those at highest risk. (Submitted by:
National Kidney Foundation)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- While GNYHA supports and understands the importance of tracking renal
dosing of anticoagulants as a patient safety measure, we do not support this
measure for adoption in the IQR or electronic Health Record (EHR) Meaningful
Use. Hospitals have had difficulty capturing and calculating electronic
measures reliably and accurately due to limitations of the currently certified
EHRs. The data points required to calculate this and other electronic clinical
quality measures are currently not readily and consistently available within
the EHR. For example, certified EHR reporting modules do not offer patient
days as a standard reportable measure. Specifically for this measure,
calculating renal dosing error will pose a challenge and may require manual
review chart review to verify and validate. Finally, many hospitals have
disparate systems and use different outpatient and inpatient systems.
Reporting on this would potentially require pulling from different source
EHRs. (Submitted by: Greater New York Hospital Association)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare
and Medicaid EHR Incentive Program for Hospitals and Critical Access
Hospitals (CAHs) ; MUC ID: X3323) |
- 4. Proper medication dosing for people with impaired renal function is
paramount to avoiding kidney failure, acute kidney injury, cardiovascular
events and other adverse events for people with kidney disease. As such, NKF
supports: ï X3323 Adverse Drug Events: - Inappropriate Renal Dosing of
Anticoagulants Patients with chronic kidney disease are at an increased risk
of bleeding when using anticoagulants; they are also more likely to be
prescribed these medications as they are more susceptible to blood clots and
venous thromboembolism (VTE). It is important that proper dosing occur for
patients with impaired kidney function, including those on dialysis. While
NKF supports the measure, we believe hospital admissions of dialysis patients
should not be excluded. NKF also does not believe that admissions, for
observation only, should be excluded as we aware of incidences where dialysis
patients have been improperly kept in observation status for multiple days,
presumably as a strategy to avoid accountability for the patient in quality
measure programs. NKF also supports this measure because it creates a
stronger incentive for hospitals to test for CKD in people with known risk
factors (e.g. diabetes, hypertension, age over 60 and family history of kidney
failure) prior to prescribing an anticoagulant to avoid the adverse event.
CKD is widely underdiagnosed even among those at highest risk. (Submitted by:
National Kidney Foundation)
- While GNYHA supports and understands the importance of tracking renal
dosing of anticoagulants as a patient safety measure, we do not support this
measure for adoption in the IQR or electronic Health Record (EHR) Meaningful
Use. Hospitals have had difficulty capturing and calculating electronic
measures reliably and accurately due to limitations of the currently certified
EHRs. The data points required to calculate this and other electronic clinical
quality measures are currently not readily and consistently available within
the EHR. For example, certified EHR reporting modules do not offer patient
days as a standard reportable measure. Specifically for this measure,
calculating renal dosing error will pose a challenge and may require manual
review chart review to verify and validate. Finally, many hospitals have
disparate systems and use different outpatient and inpatient systems.
Reporting on this would potentially require pulling from different source
EHRs. (Submitted by: Greater New York Hospital Association)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared
Savings Program; MUC ID: X3445) |
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing an alcohol screening measure, as opposed to confining it to
patients 18-34. The measure also needs to include exclusions for patient
refusal to alcohol screening and/or non-compliance with recommendations made
by providers. The measure must also adjust for socioeconomic factors as
patients who repeatedly enter the ED department due to alcoholism may not have
the necessary support and economic resources to treat the disease. We are also
not sure how you could track this information over time if the patient
utilizes various ED departments. In addition, the measure is confusing as
written as the title states ED department, but the numerator also captures
patients seen 7-days after the ER visit. (Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] While we understand the goal of the
measure, we believe the measure is poorly constructed. The evidence for the
measure is only from the Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing an alcohol screening measure, as opposed to
confining it to patients 18-34. The measure also needs to include exclusions
for patient refusal to alcohol screening and/or non-compliance with
recommendations made by providers. The measure must also adjust for
socioeconomic factors as patients who repeatedly enter the ED department due
to alcoholism may not have the necessary support and economic resources to
treat the disease. We are also not sure how you could track this information
over time if the patient utilizes various ED departments. In addition, the
measure is confusing as written as the title states ED department, but the
numerator also captures patients seen 7-days after the ER visit. (Submitted
by: American Medical Association)
| (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID: X3445)
|
- This has potential to add value. A potential burden/challenge would be
determining who would do the ASBI.(Submitted by: American Academy of
Pediatrics)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing an alcohol screening measure, as opposed to confining it to
patients 18-34. The measure also needs to include exclusions for patient
refusal to alcohol screening and/or non-compliance with recommendations made
by providers. The measure must also adjust for socioeconomic factors as
patients who repeatedly enter the ED department due to alcoholism may not have
the necessary support and economic resources to treat the disease. We are also
not sure how you could track this information over time if the patient
utilizes various ED departments. In addition, the measure is confusing as
written as the title states ED department, but the numerator also captures
patients seen 7-days after the ER visit. (Submitted by: American Medical
Association)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
- [Pre-workgroup meeting comment] While we understand the goal of the
measure, we believe the measure is poorly constructed. The evidence for the
measure is only from the Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing an alcohol screening measure, as opposed to
confining it to patients 18-34. The measure also needs to include exclusions
for patient refusal to alcohol screening and/or non-compliance with
recommendations made by providers. The measure must also adjust for
socioeconomic factors as patients who repeatedly enter the ED department due
to alcoholism may not have the necessary support and economic resources to
treat the disease. We are also not sure how you could track this information
over time if the patient utilizes various ED departments. In addition, the
measure is confusing as written as the title states ED department, but the
numerator also captures patients seen 7-days after the ER visit. (Submitted
by: American Medical Association)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3445) |
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing an alcohol screening measure, as opposed to confining it to
patients 18-34. The measure also needs to include exclusions for patient
refusal to alcohol screening and/or non-compliance with recommendations made
by providers. The measure must also adjust for socioeconomic factors as
patients who repeatedly enter the ED department due to alcoholism may not have
the necessary support and economic resources to treat the disease. We are also
not sure how you could track this information over time if the patient
utilizes various ED departments. In addition, the measure is confusing as
written as the title states ED department, but the numerator also captures
patients seen 7-days after the ER visit. (Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] While we understand the goal of the
measure, we believe the measure is poorly constructed. The evidence for the
measure is only from the Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing an alcohol screening measure, as opposed to
confining it to patients 18-34. The measure also needs to include exclusions
for patient refusal to alcohol screening and/or non-compliance with
recommendations made by providers. The measure must also adjust for
socioeconomic factors as patients who repeatedly enter the ED department due
to alcoholism may not have the necessary support and economic resources to
treat the disease. We are also not sure how you could track this information
over time if the patient utilizes various ED departments. In addition, the
measure is confusing as written as the title states ED department, but the
numerator also captures patients seen 7-days after the ER visit. (Submitted
by: American Medical Association)
| (Program: Medicare Shared Savings
Program; MUC ID: X3446) |
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing a domestic violence screening measure, as opposed to confining it
to patients 18-54. The measure also needs to include exclusions for patient
refusal to be screened for domestic violence and/or non-compliance with
recommendations by providers. The numerator only includes documented refusal
in the past year and not documented refusal during the current
encounter.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. The evidence base used to support this measure is only based on
studies of patients in Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing a domestic violence screening measure, as opposed
to confining it to patients 18-54. The measure also needs to include
exclusions for patient refusal to be screened for domestic violence and/or
non-compliance with recommendations by providers. The numerator only includes
documented refusal in the past year and not documented refusal during the
current encounter.(Submitted by: American Medical Association)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3446)
|
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing a domestic violence screening measure, as opposed to confining it
to patients 18-54. The measure also needs to include exclusions for patient
refusal to be screened for domestic violence and/or non-compliance with
recommendations by providers. The numerator only includes documented refusal
in the past year and not documented refusal during the current
encounter.(Submitted by: American Medical Association)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- Evidence of effective screening could be documented by standardized
questionnaire incorporation into the electronic or other health record.
Follow-up could be documented by a dropped down menu listing referrals. Out
comes could be tracked by future questioning at later patient encounters as to
whether abuse is decreased or ceased. Part two of that line concerns
integration of behavioral health is integrated into primary care. Those
providing behavioral health in that setting are behavioral health specialists
such as psychiatric mental health nurse practitioners, NOT family
practitioners who took an extra course in mental health. Many of the MAP
items state physician only when the provider might also be a nurse
practitioner. (Submitted by: American Psychiatric Nurses
Association)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. The evidence base used to support this measure is only based on
studies of patients in Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing a domestic violence screening measure, as opposed
to confining it to patients 18-54. The measure also needs to include
exclusions for patient refusal to be screened for domestic violence and/or
non-compliance with recommendations by providers. The numerator only includes
documented refusal in the past year and not documented refusal during the
current encounter.(Submitted by: American Medical Association)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3446) |
- It would be more advantageous for CMS to focus its resources on
constructing a measure that deals with the general Medicare population when
constructing a domestic violence screening measure, as opposed to confining it
to patients 18-54. The measure also needs to include exclusions for patient
refusal to be screened for domestic violence and/or non-compliance with
recommendations by providers. The numerator only includes documented refusal
in the past year and not documented refusal during the current
encounter.(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. The evidence base used to support this measure is only based on
studies of patients in Indian Health Services, which is separate from the
Medicare patient population. It would be more advantageous for CMS to focus
its resources on constructing a measure that deals with the general Medicare
population when constructing a domestic violence screening measure, as opposed
to confining it to patients 18-54. The measure also needs to include
exclusions for patient refusal to be screened for domestic violence and/or
non-compliance with recommendations by providers. The numerator only includes
documented refusal in the past year and not documented refusal during the
current encounter.(Submitted by: American Medical Association)
| (Program: Medicare Shared Savings
Program; MUC ID: X3465) |
- We support the MAP preliminary recommendation but would also note the
following concerns. This measure includes patients (any age) with asthma and
those 18 years or older with chest pain who visited the ED but were not
admitted. The rationale provided explains the measure focus but not why only
these two patient populations are included and what is the thinking behind
combining these populations into one measure. Because of the complexity
introduced due to the differences in patient populations (pediatric and adult)
and specialties that would provide care, it would seem appropriate to split
this measure into two rather than in one. The measure requires some type of
follow up (call or visit) within 72 hours and that the ED must have
communicated the visit to the PCP or specialist in order to be counted in the
denominator. CMS should test the measure for reliability and validity given
the complexity and dependence on data being communicated across settings prior
to implementation in any pay-for-reporting or performance program.(Submitted
by: American Medical Association)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. How is the physician going to document and track the information?
If the physician does not receive notification by the ED in a timely manner,
they may not know the patient visited the ED. The patient may also choose to
schedule an appointment post 72-hours. An ED should also have the ability to
transmit the information via facsimile to the referring physician as the
referring physician may not have an EHR that can interact or exchange
information with the ED EHR or may not have an EHR at all.(Submitted by:
American Medical Association)
| (Program: Medicare and Medicaid
EHR Incentive Programs for Eligible Professionals; MUC ID: X3465)
|
- We support the MAP preliminary recommendation but would also note the
following concerns. This measure includes patients (any age) with asthma and
those 18 years or older with chest pain who visited the ED but were not
admitted. The rationale provided explains the measure focus but not why only
these two patient populations are included and what is the thinking behind
combining these populations into one measure. Because of the complexity
introduced due to the differences in patient populations (pediatric and adult)
and specialties that would provide care, it would seem appropriate to split
this measure into two rather than in one. The measure requires some type of
follow up (call or visit) within 72 hours and that the ED must have
communicated the visit to the PCP or specialist in order to be counted in the
denominator. CMS should test the measure for reliability and validity given
the complexity and dependence on data being communicated across settings prior
to implementation in any pay-for-reporting or performance program.(Submitted
by: American Medical Association)
- How is electronic communication noted?(Submitted by: Armstrong Instititue
for Patient Safety and Quality)
- ACEP supports initiatives to further improve coordination of care and
would echo the MAPís recommendation to continue development for the
coordinating care measures listed below, but would also caution the measure
developer to consider the current health IT infrastructure currently in place,
particularly for departments not equipped with EHRs. Additionally, ACEP has
concerns regarding the logistical burden of reporting on these measures,
particularly for providers who care for a high volume of patients without a
primary care physician. ß X3466: Coordinating Care ñ Emergency Department
Referrals ß X3465: Coordinating Care ñ Follow-Up with Eligible
Provider(Submitted by: American College of Emergency Physicians Quality &
Performance Committee)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3465) |
- We support the MAP preliminary recommendation but would also note the
following concerns. This measure includes patients (any age) with asthma and
those 18 years or older with chest pain who visited the ED but were not
admitted. The rationale provided explains the measure focus but not why only
these two patient populations are included and what is the thinking behind
combining these populations into one measure. Because of the complexity
introduced due to the differences in patient populations (pediatric and adult)
and specialties that would provide care, it would seem appropriate to split
this measure into two rather than in one. The measure requires some type of
follow up (call or visit) within 72 hours and that the ED must have
communicated the visit to the PCP or specialist in order to be counted in the
denominator. CMS should test the measure for reliability and validity given
the complexity and dependence on data being communicated across settings prior
to implementation in any pay-for-reporting or performance program.(Submitted
by: American Medical Association)
- [Pre-workgroup meeting comment] A GENERAL COMMENT ABOUT THE
WORTHINESS OF THE MEASURES FOR CARE PLANNING: The CMS list still evidences a
severe shortage in the development of measures that focus on care planning.
In the CMS list, psychiatric hospital patients, ALS patients, MS patients and
hospice patients deserve a care plan, and outpatient surgeons offer to measure
whether they comply with the 1990 Patient Self-Determination Act. Surely that
leaves out most of the elderly and disabled persons who need a care plan.
What about COPD, CHF, frailty, dementia, stroke, and all of the other garden
variety ailments that afflict us as we grow old and need help. How about
people with multiple conditions, including social needs? Surely CMS should be
starting to develop and implement measures like whether persons living with
disabilities and frailty have their goals documented, have a care plan that
helps them achieve those goals, and have it available across settings. CMS
claims that desirable transformation of medical practice centers on pro-active
planning ñ so, where is it that we start to measure whether that is happening.
(Submitted by: Altarum Institute, Center for Elder Care and Advanced
Illness)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. How is the physician going to document and track the information?
If the physician does not receive notification by the ED in a timely manner,
they may not know the patient visited the ED. The patient may also choose to
schedule an appointment post 72-hours. An ED should also have the ability to
transmit the information via facsimile to the referring physician as the
referring physician may not have an EHR that can interact or exchange
information with the ED EHR or may not have an EHR at all.(Submitted by:
American Medical Association)
| (Program: Medicare Shared Savings
Program; MUC ID: X3466) |
- [Pre-workgroup meeting comment] We agree that there are times when
follow-up care needs to happen post an ED visit, but the measure is poorly
constructed. The measure only allows for coordination/exchange of information
through telephone or electronically. An ED provider should also have the
ability to transmit the information via facsimile to the referring physician
as the referring physician may not have an EHR that can interact with the ED
EHR or may not have an EHR at all. The ability to fax information becomes more
pertinent if the ED visits are non-life threatening and the patient released
after hours. It is also unclear the intent of the measure. Is CMS trying to
capture when an ED provider communicates information back to another provider?
And the fact that they called or scheduled a follow-up appointment? If so,
then the measure appears redundant and the information would have possibly
already been noted in the EHR system. However, conceivably it could also be
noted in the practice management system, if it is not integrated into the EHR.
There are also several unknowns that the measure doesnít account for. What
happens if the ED cannot get a hold of the primary care or specialist
provider? What if the patient doesnít have a primary care or specialist
provider? What if the patient doesnít want to set up a follow-up appointment
during the ED visit time? There are also very few instances where the
infrastructure exists for this information to be exchanged electronically and
possibly can only occur in integrated delivery systems. For the information to
be able to be exchanged electronically outside of disparate EHRs, the ED and
the primary care or specialist physician would need access to the same health
information exchange. (Submitted by: American Medical
Association)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3466)
|
- We support the MAP preliminary recommendation but recommend that the
additional note be made regarding the measure construction. The measure
requires that the ED communicate about the visit to the PCP or specialist but
it does not exclude or in any way address patients who present in the ED
without an existing relationship with a PCP or specialist, which commonly
occurs. ED physician performance could be negatively impacted due to the
number of patients who seek care in an ED because they do not have a PCP or
specialist. CMS should address this concern and test the measure for
reliability and validity given the complexity prior to implementation in any
pay-for-reporting or performance program.There are also very few instances
where the infrastructure exists for this information to be exchanged
electronically and possibly can only occur in a large health system. For the
information to be able to be exchanged electronically outside of disparate
EHRs, the ED and the primary care or specialist physician would need access to
the same health information exchange. (Submitted by: American Medical
Association)
- ACEP supports initiatives to further improve coordination of care and
would echo the MAPís recommendation to continue development for the
coordinating care measures listed below, but would also caution the measure
developer to consider the current health IT infrastructure currently in place,
particularly for departments not equipped with EHRs. Additionally, ACEP has
concerns regarding the logistical burden of reporting on these measures,
particularly for providers who care for a high volume of patients without a
primary care physician. ß X3466: Coordinating Care ñ Emergency Department
Referrals ß X3465: Coordinating Care ñ Follow-Up with Eligible
Provider(Submitted by: American College of Emergency Physicians Quality &
Performance Committee)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
- [Pre-workgroup meeting comment] We believe this measure is poorly
constructed. How is the physician going to document and track the information?
If the physician does not receive notification by the ED in a timely manner,
they may not know the patient visited the ED. The patient may also choose to
schedule an appointment post 72-hours. An ED should also have the ability to
transmit the information via facsimile to the referring physician as the
referring physician may not have an EHR that can interact or exchange
information with the ED EHR or may not have an EHR at all.(Submitted by:
American Medical Association)
- [Pre-workgroup meeting comment] We agree that there are times when
follow-up care needs to happen post an ED visit, but the measure is poorly
constructed. The measure only allows for coordination/exchange of information
through telephone or electronically. An ED provider should also have the
ability to transmit the information via facsimile to the referring physician
as the referring physician may not have an EHR that can interact with the ED
EHR or may not have an EHR at all. The ability to fax information becomes more
pertinent if the ED visits are non-life threatening and the patient released
after hours. It is also unclear the intent of the measure. Is CMS trying to
capture when an ED provider communicates information back to another provider?
And the fact that they called or scheduled a follow-up appointment? If so,
then the measure appears redundant and the information would have possibly
already been noted in the EHR system. However, conceivably it could also be
noted in the practice management system, if it is not integrated into the EHR.
There are also several unknowns that the measure doesnít account for. What
happens if the ED cannot get a hold of the primary care or specialist
provider? What if the patient doesnít have a primary care or specialist
provider? What if the patient doesnít want to set up a follow-up appointment
during the ED visit time? There are also very few instances where the
infrastructure exists for this information to be exchanged electronically and
possibly can only occur in integrated delivery systems. For the information to
be able to be exchanged electronically outside of disparate EHRs, the ED and
the primary care or specialist physician would need access to the same health
information exchange. (Submitted by: American Medical
Association)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3466) |
- In pediatric populations, especially with asthma, this measure might add
value in terms of primary care awareness and a hand off of sorts. This has the
potential to increase primary care utilization, increase the primary care
providerís awareness of the patientís needs, and to promote more optimal
asthma care. This would not create an undue reporting/data collection burden
if an EMR can transmit documentation electronically. Phone calls and the lack
of ability to fax may be other barriers. A potential barrier to full
implementation of this measure would be if the ED visit occurred over a
weekend or holiday, when the PCP may not receive the referral within 24 hours.
Other conditions such as obesity, mental health might be considered.
(Submitted by: American Academy of Pediatrics)
- Would addition of the measure add value to the program measure set? Yes
What is the measureís potential to improve patient outcomes? Differentiating
the follow up interval between asthma and chest pain does make sense from a
clinical perspective as does excluding chest pain due to trauma. Would use of
the measure create undue data collection or reporting burden? No Is there a
better measure available or does a measure already in the program set address
a particular program objective? The changes made are appropriate. The measure
is an improvement over the prior iteration.(Submitted by: American Geriatrics
Society)
- We support the MAP preliminary recommendation but recommend that the
additional note be made regarding the measure construction. The measure
requires that the ED communicate about the visit to the PCP or specialist but
it does not exclude or in any way address patients who present in the ED
without an existing relationship with a PCP or specialist, which commonly
occurs. ED physician performance could be negatively impacted due to the
number of patients who seek care in an ED because they do not have a PCP or
specialist. CMS should address this concern and test the measure for
reliability and validity given the complexity prior to implementation in any
pay-for-reporting or performance program.There are also very few instances
where the infrastructure exists for this information to be exchanged
electronically and possibly can only occur in a large health system. For the
information to be able to be exchanged electronically outside of disparate
EHRs, the ED and the primary care or specialist physician would need access to
the same health information exchange.(Submitted by: American Medical
Association)
- [Pre-workgroup meeting comment] We agree that there are times when
follow-up care needs to happen post an ED visit, but the measure is poorly
constructed. The measure only allows for coordination/exchange of information
through telephone or electronically. An ED provider should also have the
ability to transmit the information via facsimile to the referring physician
as the referring physician may not have an EHR that can interact with the ED
EHR or may not have an EHR at all. The ability to fax information becomes more
pertinent if the ED visits are non-life threatening and the patient released
after hours. It is also unclear the intent of the measure. Is CMS trying to
capture when an ED provider communicates information back to another provider?
And the fact that they called or scheduled a follow-up appointment? If so,
then the measure appears redundant and the information would have possibly
already been noted in the EHR system. However, conceivably it could also be
noted in the practice management system, if it is not integrated into the EHR.
There are also several unknowns that the measure doesnít account for. What
happens if the ED cannot get a hold of the primary care or specialist
provider? What if the patient doesnít have a primary care or specialist
provider? What if the patient doesnít want to set up a follow-up appointment
during the ED visit time? There are also very few instances where the
infrastructure exists for this information to be exchanged electronically and
possibly can only occur in integrated delivery systems. For the information to
be able to be exchanged electronically outside of disparate EHRs, the ED and
the primary care or specialist physician would need access to the same health
information exchange. (Submitted by: American Medical
Association)
| (Program:
Medicare and Medicaid EHR Incentive Programs for Eligible Professionals;
MUC ID: X3468) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3468) |
- This measure, under consideration for the Medicare Shared Savings Program
(MSSP), the PQRS, Value Modifier, and Physician Compare, evaluates 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. The MAP
encourages ìcontinued developmentî of this measure for all of these programs.
The MAP recognizes the importance of this measure for the Medicare population
and dual eligible, in particular, but believes the measure should include
advanced directives and patient goals to ensure the proxy is informed and
aware of the patientís wishes. The AAHPM believes this is a meaningful measure
and can actually be a valuable source of data when combined with other
outcomes (e.g., percent with identified healthcare proxy transitioned to
hospice versus not identified). However, this measure should not be limited
to those with a positive result on a standardized assessment or diagnosis.
Those who are likely to develop cognitive decline for medical reasons (e.g.
known brain tumor, advanced liver disease, etc.) should be able to be included
whether they progress to full impairment or die beforehand. As noted earlier,
a larger denominator will help make this more meaningful as the primary goal
is to document these decisions before the person can no longer decide for
him/herself.(Submitted by: AAHPM)
- AGS agrees that this is an important measure to include. (Submitted by:
American Geriatrics Society)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- This measure, under consideration for the Medicare Shared Savings Program
(MSSP), the PQRS, Value Modifier, and Physician Compare, evaluates 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. The MAP
encourages ìcontinued developmentî of this measure for all of these programs.
The MAP recognizes the importance of this measure for the Medicare population
and dual eligible, in particular, but believes the measure should include
advanced directives and patient goals to ensure the proxy is informed and
aware of the patientís wishes. AAHPM believes this is a meaningful measure and
can actually be a valuable source of data when combined with other outcomes
(e.g., percent with identified healthcare proxy transitioned to hospice versus
not identified). However, this measure should not be limited to those with a
positive result on a standardized assessment or diagnosis. Those who are
likely to develop cognitive decline for medical reasons (e.g. known brain
tumor, advanced liver disease, etc.) should be able to be included whether
they progress to full impairment or die beforehand. As noted earlier, a larger
denominator will help make this more meaningful as the primary goal is to
document these decisions before the person can no longer decide for
him/herself.(Submitted by: American Academy of Hospice and Palliative
Medicine)
- ASN supports documentation of health care proxies for all individuals with
advanced chronic diseases.(Submitted by: American Society of Nephrology
(ASN))
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] ASN supports documentation of
health care proxies for all individuals with advanced chronic
diseases.(Submitted by: American Society of Nephrology (ASN))
| (Program: Medicare and
Medicaid EHR Incentive Programs for Eligible Professionals; MUC ID: X3469)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3469) |
- AGS agrees with this measure as being important to assess older adults by
primary care as this would affect care recommendations for patients.
(Submitted by: American Geriatrics Society)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- ASN supports this measure in concept, but believes this measure
potentially should be applied to younger patients as well as older if
including kidney failure patients. ASN notes that cognitive impairment
patterns may be different in non-dialysis CKD and dialysis patients, and that
cognitive performance may not be accurately assessed by Alzheimerís screening
tools like the Mini-Mental State Examination, and ASN stresses that there
needs to be validation of cognitive screening tests in the CKD populations in
order for screening to be useful. (Submitted by: American Society of
Nephrology (ASN))
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] ASN supports this measure in
concept, but believes this measure potentially should be applied to younger
patients as well as older if including kidney failure patients. ASN notes that
cognitive impairment patterns may be different in non-dialysis CKD and
dialysis patients, and that cognitive performance may not be accurately
assessed by Alzheimerís screening tools like the Mini-Mental State
Examination, and ASN stresses that there needs to be validation of cognitive
screening tests in the CKD populations in order for screening to be
useful.(Submitted by: American Society of Nephrology (ASN))
| (Program:
Medicare and Medicaid EHR Incentive Programs for Eligible Professionals;
MUC ID: X3472) |
- Why is this measure not in the "support" category?(Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- This is not necessarily a quality indicator. What would the results be
used for?(Submitted by: American Academy of Pediatrics)
- X3323 - X 3472: There are several elements listed between 150-170's that
refer to substance abuse, cognitive changes and pediatric antipsychotic
prescribing in which the ROLE of the nurse in doing consistent mental health
and substance abuse assessments, as well as cognitive changes noticed on
inpatient and outpatient follow up should be recognized. Faculty should be
encouraged to review the list. Since they are preparing new graduates (BSN,
MSN, DNP) these elements are important to competency of the future clinicians.
Note that the language of who is to assess and monitor the value is
"clinician", which could mean anything from LPN, MA to MD. We want NURSING or
psychiatric nurses to monitor and appropriately assess and refer to illustrate
how psychiatric nursing is an essential part of all nursing. (Submitted by:
American Psychiatric Nurses Association)
| (Program: Medicare Shared Savings
Program; MUC ID: X3475) |
- I strongly support inclusion of this substance use screening and
intervention composite measure in the Medicare Shared Savings Program.
Substance use disorders (SUDs) are a critical risk factor for chronic medical
illnesses and complication of their treatment, and they should not be ignored.
According to U.S. national surveys, SUDs marked by hazardous use of alcohol,
tobacco products, non-prescribed drugs and illicit drugs affect approximately
20 percent of adult populations. Approximately 8 to 10 percent of adults have
the most serious form of SUDs - addiction. An additional 40 million adults use
substances in a way that substantially interferes with their health and
healthcare. SUDs produce a wide variety of medical problems and are important
contributors to years of life lost due to disability and preventable death.
When unaddressed in the treatment of other medical illnesses, SUDs generally
produce poor adherence to medications; poor control of hypertension and
diabetes; increased risk for a host of cancers and medical illnesses;
increased risk for transmission of HIV and other sexually transmitted
diseases; and decreased effectiveness of treatments for chronic pain.
Furthermore, prescription drug overdose is now the leading cause of accidental
death in the United States - surpassing motor vehicle accidents. Yet,
screening, intervening, and treating SUDs have not been embraced within
primary care settings. In fact, even though untreated SUDs place individuals
at significantly greater risk for a wide range of diseases and are a
significant public health burden, only one tenth of Americans with SUDs
received treatment in 2013 partly due to gross under-screening and
intervention in primary care settings. This rendering of patients with
hazardous drug use as largely invisible in primary care settings is very
problematic in that it is impossible to safely prescribe medication to
patients without knowing if they are on illicit drugs, or misusing
prescription drugs. Further, if primary care physicians do not screen for
hazardous drug use, guided by pertinent clinical quality measures in
electronic health record systems to do so, it will go undetected or
under-detected and likely confound patient-centered care. This composite
measure will help address the worsening epidemic of medically harmful drug
use. Since SUDs produce a wide variety of medical problems, the Patient
Protection and Affordable Care Act requires most private insurers to expand
coverage and access to a range of care options for prevention, early
intervention, treatment and continuing management of substance use disorders.
Insurers also must ensure these benefits comply with the Mental Health Parity
and Addiction Equity Act. Consequently, it is necessary that health care
providers in general medical settings be equipped to become competent in
implementing and managing effective substance misuse prevention and treatment
interventions. One key means to enable this is for providers to be provided
appropriate training and resources to support and guide evidence-based
screening and intervention for SUDs in primary care settings, utilizing
relevant electronic-health-record-based clinical quality measures and
accompanying evidence-based, point-of-care clinical decision support (CDS)
tools. Since 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 hazardous substance use (and pharmacotherapy for tobacco use) has been
shown to be an effective intervention for reducing problem use in primary care
settings. In addition, for many patients presenting for primary care with
hazardous drug use, learning the consequences of their ìat riskî behavior or
abuse can provide a teachable moment and the wake-up call they need to either
stop using or seek appropriate follow-up treatment. All the components within
the Substance Use Screening and Intervention Composite Measure (tobacco use,
unhealthy alcohol use, illicit drug use, and non-medical prescription drug
use) are clinically significant public health issues that would benefit from
the implementation of this measure. This composite measure does not, however,
mitigate the importance of the individual component measures. In fact, the
component measures within this composite independently evaluate the percentage
of patients screened AND provided the intervention. The composite then
aggregates the component outcome data using an opportunity-based composite
scoring approach in which each component contributes equally and independently
to the composite outcome. Hence, this measure both focuses on reporting each
component separately and also reduces information burden by synthesizing
available metrics into a simple overall picture of performance at the
composite level. In this manner, this composite measure tracks a wider range
of indicators than would be otherwise possible in a comprehensive yet
parsimonious way. In summary, I support this measureís inclusion in this CMS
Program. There is an urgent public health need for such a clinical quality
measure be incorporated in electronic health record systems (EHR) and to
incentivize providers to systematic identify (currently grossly undetected)
patients with hazardous substance use in primary care settings, which is
necessary to support integrated care and to move patients with substance use
disorders into appropriate evidence-based prevention/treatment interventions
(including medication-assisted treatment). There is also an important need for
the high-value information captured in this composite measure to be recorded
in the EHR and linked to multiple aspects of clinical decision-making and
clinical decision support tools for appropriate interventions. Sincerely,
Dr. Udi E. Ghitza (Submitted by: Dr. Udi E. Ghitza)
- see incentive program comments(Submitted by: Boston Medical Center/Boston
University)
- I have reviewed the scientific evidence for the proposed Measure Under
Consideration (MUC) X3475: Substance Use Screening and Intervention Composite
(for tobacco use, alcohol use, illicit drug use and prescription drug abuse),
both as a scientist who assesses such clinical evidence (e.g., Chair, USPHS
Tobacco Cessation Clinical Practice Guideline Panels) and as a practicing
primary care physician. Based on this review, my conclusion is that the
illicit and prescription drug abuse components of MUC X3475 have insufficient
evidence for endorsement. Moreover, these measures would result in a
substantial and unsupported burden on primary care leading me to recommend
against endorsement. Specifically: 1) United States Preventive Services
Task Force Review (USPSTF): USPSTF has not endorsed illicit and prescription
drug screening and intervention. 2) Two key JAMA articles: Two recent
(8/6/14) JAMA articles (Saitz et al: Screening and brief intervention for drug
use in primary care: the ASPIRE randomized clinical trial + Roy-Byrne et al:
Brief intervention for problem drug use in safety-net primary care settings: a
randomized clinical trial) drew a consistent conclusion: "Brief intervention
did not have efficacy for decreasing unhealthy drug use in primary care
patients identified by screening.î 3) Accompanying JAMA Editorial: The
importance of these 2 articles was underscored by an accompanying NIH
editorial (Hingson and Compton: Screening and Brief Intervention and Referral
to Treatment for Drug Use in Primary Care - Back to the Drawing Board). The
title clearly states their conclusions. 4) NQF Evaluation of the Scientific
Evidence for MUC X3475: Several members of the NQF Measure Applications
Partnership (MAP) Clinician Work Group expressed significant concerns that the
two components of MUC X3475 relating to drug use are not evidence-based. The
MAP Clinician Work Group acknowledged the strong evidence base for tobacco and
alcohol screening and intervention. 5) Burden: The United States health
care system is under incredible stress - ACA, Meaningful Use, performance
measures, EHR implementation. How can we recommend universal adoption of a
complex and burdensome screening and intervention composite measure when we
don't have a consistent evidence base to support two components of it? In
conclusion, my review of the evidence is that MUC X3475 as it currently exists
is just not ready for endorsement and implementation. I think the composite
measure also poses a threat in terms of potentially undermining recommended
screening and brief interventions for the two major health risks for which
there is a powerful and consistent evidence base ñ tobacco and alcohol. More
evidence in the future might provide a compelling case for illegal and
prescription drug screening and intervention. But, at this point, we lack
such evidence to move forward with the illegal and prescription drug
components of MUC X3475. Michael Fiore, MD, MPH, MBA(Submitted by: University
of Wisconsin School of Medicine and Public Health Center for Tobacco Research
and Intervention)
- [Pre-workgroup meeting comment] I am Medical Director for
Preventive Care at Group Health (GH), an integrated delivery system and health
plan that serves almost 600,000 members in Washington and Idaho. I am writing
to you to express GHís concern about this measure on the annual CMS Measures
Under Consideration (MUC) list. This measure combines screening and
intervention for tobacco use, unhealthy alcohol use, nonmedical prescription
drug use, and illicit drug use. GH is concerned that the proposed measure
combines both evidence-based processes of care (screening and brief
intervention (SBI) for tobacco use and unhealthy alcohol use) and
non-evidence-based (SBI for prescription drug abuse and illicit drug use)
processes of care into a single bundled measure. Our concerns revolve around
these issues: 1. Lack of evidence for screening for substance use disorders.
While population-based substance use screening has great potential merit, no
rigorous study has examined the impact of substance use screening and
assessment for substance use disorders, compared to usual care without
screening. In fact, two recent trials comparing screening and BI to screening
without BI found no added effects (Roy-Byrne et al, 2014 and Saitz et al,
2014). Our research team at the Group Health Research Institute, led by Dr.
Katharine Bradley, is engaged in research efforts to develop ways address
screening for drug use and ensure that identified individuals benefit from
treatment. 2. Impact of bundling on provider engagement in tobacco and alcohol
processes of care. GH has been a leader in tobacco screening and
intervention, and we have worked hard to embed these processes into clinical
care. Our ongoing work in the area of alcohol screening and intervention is
aimed in part at breaking down providersí misconceptions about alcohol use and
educating providers about treatment options, with the goal of embedding
evidence-based care for alcohol related conditions into standard clinical
work. As in all health care organizations, considerable effort is required to
support providers in adopting evidence-based processes of care for tobacco and
alcohol screening and interventions. The strong evidence base for tobacco and
alcohol has been important in building this support among providers. We are
concerned that this combined measure (that includes processes of care that
lack evidence) will undermine our efforts in tobacco and alcohol.
3. Competing/perverse incentives for providers. The bundled measure requires
that all four processes of care be completed to receive credit. This could
create incentives for providers to focus on increasing their SBI rates for
prescription drug abuse and illicit drug use (which will be starting from very
low baseline rates), at the expense of continuing to improve SBI rates for
tobacco and alcohol use, which are likely to be higher, but still far from
ideal. The separate measures that already exist for SBI for tobacco use and
unhealthy alcohol use are preferable for this reason. 4. Lack of evidence for
a bundled measure. We need more data on the effect of bundling these measures
on processes of care in real world settings before implementation.
5. Reimbursement confusion. The combined measure also creates confusion
regarding reimbursement, since the tobacco and alcohol activities are
recommended by USPSTF and thus are reimbursable, whereas
screening/intervention for nonmedical prescription drug use and illicit drug
use are not. Note: These comments apply to MUC X3475, across all pertinent
programs: Medicare and Medicaid EHR Incentive Program for Eligible
Physicians; Medicare Physician Quality Reporting system/Physician Compare; and
Medicare Shared Savings References Roy-Byrne P, Bumgardner K, Krupski A, Dunn
C, Ries R, Donovan D, West, II, Maynard C, Atkins DC, Graves MC, Joesch JM,
Zarkin GA. Brief intervention for problem drug use in safety-net primary care
settings: a randomized clinical trial. JAMA. 2014;312(5):492-501. Saitz R,
Cheng DM, Allensworth-Davies D, Winter MR, Smith PC. The ability of single
screening questions for unhealthy alcohol and other drug use to identify
substance dependence in primary care. J Stud Alcohol Drugs.
2014;75(1):153-157. PMCID: PMC3893629. (Submitted by: Group
Health)
- [Pre-workgroup meeting comment] I strongly support use of this
measure. Recent JAMA studies finding drug interventions ineffective focused
only on severely disadvantaged patients. This metric would only be a first
step in the right direction, as it will not reflect the quality of the
intervention. Mere brief advice would satisfy the metric but not elicit the
behavior change and the cost savings obtained in prior RCTs.(Submitted by:
Wisconsin Initiative to Promote Healthy Lifestyles)
- [Pre-workgroup meeting comment] I have serious reservations
regarding the inclusion of nonmedical prescription drug use and illicit drug
use in a screening and brief counseling measure, particularly as combined with
alcohol and tobacco. There is no evidence, of which I am aware, that builds
the scientific evidence for applying such SBI protocol to non medical
prescription drug use and illicit drug use. By doing so, we not only take
critical resources away from addressing alcohol issues in a clinical setting,
but we also diminish the credibility in areas of substance abuse prevention
where the science is solid. I would strongly urge that the metrics be based in
strong evidence and that we not burden health care personnel when the evidence
is not available, thus detracting from the important work that could be
supported around alcohol using SBI.(Submitted by: US Alcohol Policy
Alliance)
- [Pre-workgroup meeting comment] Comments from the American Society
of Addiction Medicine December 5, 2014 Untreated substance use disorders
(SUDs) place individuals at significantly greater risk for a wide range of
diseases and are a significant public health burden, yet only one tenth of
Americans with SUDs received treatment in 2012. Screening and brief
intervention has been shown to be an effective tool for identifying and
treating substance use disorders in primary care settings. However, screening
and brief intervention remains an underutilized early intervention mechanism.
The Substance Use Screening and Intervention Composite Measure was submitted
to the NQF Behavioral Health Committee as a trial measure and was reviewed on
October 2. This measure is intended to assess the extent to which primary
care patients receive evidence-based screenings for potential misuse of
several categories of substances, including tobacco, alcohol, and licit and
illicit drugs. The measure assesses the percent of patients who are screened
for unhealthy tobacco, alcohol, and drug use and the percent that are offered
an intervention in response to a positive screen. The component measures
within the composite each look independently at the percent of patients
screened AND provided the brief intervention or counseling. The composite
then aggregates the component outcome data using an opportunity-based
composite scoring approach where each component contributes equally to the
composite outcome. As it was designed, the measure focuses on reporting and
monitoring of each component separately, while also giving an overall picture
of performance at the composite level. Composite measure benefits include
reducing the information burden by distilling the available indicators into a
simple summary, tracking a broader range of metrics than would be possible
otherwise, and making provider assessments more comprehensive. All the
components within the Substance Use Screening and Intervention Composite
Measure (alcohol, tobacco and drugs) are significant public health issues that
would benefit from the implementation of this measure. Furthermore, it
captures the tendency for polysubstance use among this patient population.
(Submitted by: American Society of Addiction Medicine)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3475)
|
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- I strongly support inclusion of this substance use screening and
intervention composite measure in the Medicare and Medicaid EHR Incentive
Program for Eligible Professionals. Substance use disorders (SUDs) are a
critical risk factor for chronic medical illnesses and complication of their
treatment, and they should not be ignored. According to U.S. national surveys,
SUDs marked by hazardous use of alcohol, tobacco products, non-prescribed
drugs and illicit drugs affect approximately 20 percent of adult populations.
Approximately 8 to 10 percent of adults have the most serious form of SUDs -
addiction. An additional 40 million adults use substances in a way that
substantially interferes with their health and healthcare. SUDs produce a wide
variety of medical problems and are important contributors to years of life
lost due to disability and preventable death. When unaddressed in the
treatment of other medical illnesses, SUDs generally produce poor adherence to
medications; poor control of hypertension and diabetes; increased risk for a
host of cancers and medical illnesses; increased risk for transmission of HIV
and other sexually transmitted diseases; and decreased effectiveness of
treatments for chronic pain. Furthermore, prescription drug overdose is now
the leading cause of accidental death in the United States - surpassing motor
vehicle accidents. Yet, screening, intervening, and treating SUDs have not
been embraced within primary care settings. In fact, even though untreated
SUDs place individuals at significantly greater risk for a wide range of
diseases and are a significant public health burden, only one tenth of
Americans with SUDs received treatment in 2013 partly due to gross
under-screening and intervention in primary care settings. This rendering of
patients with hazardous drug use as largely invisible in primary care settings
is very problematic in that it is impossible to safely prescribe medication to
patients without knowing if they are on illicit drugs, or misusing
prescription drugs. Further, if primary care physicians do not screen for
hazardous drug use, guided by pertinent clinical quality measures in
electronic health record systems to do so, it will go undetected or
under-detected and likely confound patient-centered care. This composite
measure will help address the worsening epidemic of medically harmful drug
use. Since SUDs produce a wide variety of medical problems, the Patient
Protection and Affordable Care Act requires most private insurers to expand
coverage and access to a range of care options for prevention, early
intervention, treatment and continuing management of substance use disorders.
Insurers also must ensure these benefits comply with the Mental Health Parity
and Addiction Equity Act. Consequently, it is necessary that health care
providers in general medical settings be equipped to become competent in
implementing and managing effective substance misuse prevention and treatment
interventions. One key means to enable this is for providers to be provided
appropriate training and resources to support and guide evidence-based
screening and intervention for SUDs in primary care settings, utilizing
relevant electronic-health-record-based clinical quality measures and
accompanying evidence-based, point-of-care clinical decision support (CDS)
tools. Since 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 hazardous substance use (and pharmacotherapy for tobacco use) has been
shown to be an effective intervention for reducing problem use in primary care
settings. In addition, for many patients presenting for primary care with
hazardous drug use, learning the consequences of their ìat riskî behavior or
abuse can provide a teachable moment and the wake-up call they need to either
stop using or seek appropriate follow-up treatment. All the components within
the Substance Use Screening and Intervention Composite Measure (tobacco use,
unhealthy alcohol use, illicit drug use, and non-medical prescription drug
use) are clinically significant public health issues that would benefit from
the implementation of this measure. This composite measure does not, however,
mitigate the importance of the individual component measures. In fact, the
component measures within this composite independently evaluate the percentage
of patients screened AND provided the intervention. The composite then
aggregates the component outcome data using an opportunity-based composite
scoring approach in which each component contributes equally and independently
to the composite outcome. Hence, this measure both focuses on reporting each
component separately and also reduces information burden by synthesizing
available metrics into a simple overall picture of performance at the
composite level. In this manner, this composite measure tracks a wider range
of indicators than would be otherwise possible in a comprehensive yet
parsimonious way. In summary, I support this measureís inclusion in this CMS
Program. There is an urgent public health need for such a clinical quality
measure be incorporated in electronic health record systems (EHR) and to
incentivize providers to systematic identify (currently grossly undetected)
patients with hazardous substance use in primary care settings, which is
necessary to support integrated care and to move patients with substance use
disorders into appropriate evidence-based prevention/treatment interventions
(including medication-assisted treatment). There is also an important need for
the high-value information captured in this composite measure to be recorded
in the EHR and linked to multiple aspects of clinical decision-making and
clinical decision support tools for appropriate interventions. Sincerely,
Dr. Udi E. Ghitza (Submitted by: Dr. Udi E. Ghitza)
- I am a primary care physician and researcher who has focused his career
and clinical and research efforts for almost 25 years to improving care for
people with unhealthy alcohol and other drug use. I validated alcohol and
drug screening questions for use in primary care practice (when indicated) and
I have trained legions of physicians on how to screen and intervene for
alcohol and drugs when appropriate. As such, my opposition to this measure
should be notable. A combined measure that would apply to all patients
universally is not a good idea. The state of the science suggests that
screening and brief intervention for drug use will not impact the huge problem
of drug use and may distract from attention to help-seekers with recognized
problems. Individual measures for alcohol and tobacco already exist. Specific
reasons include the following and these have been updated since my initial
comments. 1. Current screening tools are designed to detect drug use
that risks consequences in order to then do a brief intervention aimed at
reducing substance use or referring people to specialized treatment.
Additional questions (not well studied) are needed to identify what a
clinician needs to know to prescribe safely or diagnose related conditions.
Thus, the idea that ëdrug use is a big problem, an epidemicí, while true, will
not be impacted. Just because something is a big and important problem does
not mean one should implement something that is ineffective. Screening to
prescribe and diagnose is completely different from screening to identify and
intervene in drug use. This is often misunderstood even by experts in the
field who are focused on doing whatever might be possible regardless of
efficacy or costs or consequences, or what it will really be like for
practicing clinicians wishing to use the information. 2. There is high
quality randomized trial evidence with biological outcomes that drug screening
and brief intervention has no efficacy in primary care and emergency
department settings (and no such evidence that it has meaningful efficacy
anywhere). The idea that extant trials are not relevant because many patients
were disadvantaged is simply bizarre. While true that patients studied had
high rates of unemployment (as an example), two trials were in urban centers
but 82% of patients did not have even a moderate or severe drug use disorder
(these 82% had mild or no disorder---they simply had risky drug use). So we
know that a two session (offered) brief counseling intervention does not work,
at least not in urban centers. We have a multisite randomized trial in
emergency departments finding no efficacy. Other studies used self report and
had little convincing effect (high loss to follow-up, social desirability
bias, and absent effects in the US for exampleóthis literature is well known,
but ignored by advocates who cite evidence in favor of screening and brief
intervention that comes from alcohol and tobacco studies, ignoring how it does
not apply to drugs, and there is good reason why it does not apply). It
should also be noted that there simply is no positive evidence for efficacy.
So we are left with a practice that has no efficacy in cities, and the hope
that it might work somewhere else (wealthy suburbs perhaps? Why? And what
impact would that have? What utility?) that has not been detected yet in
trials. Given how different drug use is from risky alcohol use, most people
are not surprised that brief intervention for cocaine or heroin use or the
very complex problem of prescription opioid misuse lacks efficacy. 3.
Measures that use the construct of brief intervention among patients screened
as a quality measure can worsen the quality of care. The measure looks better
(paradoxically) when fewer people are screened, and this tends to encourage
only addressing more severe use and not the (larger) lower risk end of the
spectrum of unhealthy use (that is more amenable to intervention). 4.
Asking about other drugs is complex and has legal implications (it documents
illegal behavior in medical records). SAMHSA has recently asked HHS to keep
records that document substance use secret from research and to put barriers
in place to record access. This means that a measure such as this could
worsen quality of care by adding drug documentation to medical records which
could then impede access to such records by caregivers. Such issues must be
resolved before any universal requirement to screen. At the very least the
potential harms of drug screening should be well understood and compared to
the potential benefits (which so far lack any evidence---wishing for efficacy
does not make a practice efficacious). It may be a good idea but it should
likely be addressed (when the science supports it, and when protections are in
place for patients) as a separate measure. 5. A composite is not a good idea.
It could impact evidence-based tobacco and alcohol screening and brief
intervention that is recommended by the USPSTF while drug screening is not.
Improving tobacco and alcohol identification and intervention may be much
harder if they are tied to having to identify and intervene for numerous
specific illicit drugs. These are practical issues that may be ignored by
those no longer in (or never in) practice who may comment in favor. 6.
It is difficult if not impossible to use a composite measure to lead to an
improvement in quality of care since it is not clear what should be improved.
The idea that the individual components can be separated out to solve this
problem further emphasizes that it would be better to have the individual
components separate in the first place. Also, a systematic review by Kaner et
al 2011 in the journal Mental Health and Substance Use found that brief
intervention was not effective when more than one substance was used or when
there was mental health comorbidity. 7. Unlike alcohol and tobacco,
USPSTF does not recommend universal drug screening. Large national health
organizations (i.e. the VA, Group Health) that implement alcohol and tobacco
universal screening do not do so for other drugs. These huge organizations
have carefully considered the issues without a focus on specific advocacy, but
rather with an eye towards improving the health of their populations. 8. It
is not a good idea to tie financial or other incentives for providers to a
measure that lacks evidence.(Submitted by: Boston Medical Center/Boston
University)
- I have reviewed the scientific evidence for the proposed Measure Under
Consideration (MUC) X3475: Substance Use Screening and Intervention Composite
(for tobacco use, alcohol use, illicit drug use and prescription drug abuse),
both as a scientist who assesses such clinical evidence (e.g., Chair, USPHS
Tobacco Cessation Clinical Practice Guideline Panels) and as a practicing
primary care physician. Based on this review, my conclusion is that the
illicit and prescription drug abuse components of MUC X3475 have insufficient
evidence for endorsement. Moreover, these measures would result in a
substantial and unsupported burden on primary care leading me to recommend
against endorsement. Specifically: 1) United States Preventive Services
Task Force Review (USPSTF): USPSTF has not endorsed illicit and prescription
drug screening and intervention. 2) Two key JAMA articles: Two recent
(8/6/14) JAMA articles (Saitz et al: Screening and brief intervention for drug
use in primary care: the ASPIRE randomized clinical trial + Roy-Byrne et al:
Brief intervention for problem drug use in safety-net primary care settings: a
randomized clinical trial) drew a consistent conclusion: "Brief intervention
did not have efficacy for decreasing unhealthy drug use in primary care
patients identified by screening.î 3) Accompanying JAMA Editorial: The
importance of these 2 articles was underscored by an accompanying NIH
editorial (Hingson and Compton: Screening and Brief Intervention and Referral
to Treatment for Drug Use in Primary Care - Back to the Drawing Board). The
title clearly states their conclusions. 4) NQF Evaluation of the Scientific
Evidence for MUC X3475: Several members of the NQF Measure Applications
Partnership (MAP) Clinician Work Group expressed significant concerns that the
two components of MUC X3475 relating to drug use are not evidence-based. The
MAP Clinician Work Group acknowledged the strong evidence base for tobacco and
alcohol screening and intervention. 5) Burden: The United States health
care system is under incredible stress - ACA, Meaningful Use, performance
measures, EHR implementation. How can we recommend universal adoption of a
complex and burdensome screening and intervention composite measure when we
don't have a consistent evidence base to support two components of it? In
conclusion, my review of the evidence is that MUC X3475 as it currently exists
is just not ready for endorsement and implementation. I think the composite
measure also poses a threat in terms of potentially undermining recommended
screening and brief interventions for the two major health risks for which
there is a powerful and consistent evidence base ñ tobacco and alcohol. More
evidence in the future might provide a compelling case for illegal and
prescription drug screening and intervention. But, at this point, we lack
such evidence to move forward with the illegal and prescription drug
components of MUC X3475. Michael Fiore, MD, MPH, MBA (Submitted by: University
of Wisconsin School of Medicine and Public Health Center for Tobacco Research
and Intervention)
- [Pre-workgroup meeting comment] I am Medical Director for
Preventive Care at Group Health (GH), an integrated delivery system and health
plan that serves almost 600,000 members in Washington and Idaho. I am writing
to you to express GHís concern about this measure on the annual CMS Measures
Under Consideration (MUC) list. This measure combines screening and
intervention for tobacco use, unhealthy alcohol use, nonmedical prescription
drug use, and illicit drug use. GH is concerned that the proposed measure
combines both evidence-based processes of care (screening and brief
intervention (SBI) for tobacco use and unhealthy alcohol use) and
non-evidence-based (SBI for prescription drug abuse and illicit drug use)
processes of care into a single bundled measure. Our concerns revolve around
these issues: 1. Lack of evidence for screening for substance use disorders.
While population-based substance use screening has great potential merit, no
rigorous study has examined the impact of substance use screening and
assessment for substance use disorders, compared to usual care without
screening. In fact, two recent trials comparing screening and BI to screening
without BI found no added effects (Roy-Byrne et al, 2014 and Saitz et al,
2014). Our research team at the Group Health Research Institute, led by Dr.
Katharine Bradley, is engaged in research efforts to develop ways address
screening for drug use and ensure that identified individuals benefit from
treatment. 2. Impact of bundling on provider engagement in tobacco and alcohol
processes of care. GH has been a leader in tobacco screening and
intervention, and we have worked hard to embed these processes into clinical
care. Our ongoing work in the area of alcohol screening and intervention is
aimed in part at breaking down providersí misconceptions about alcohol use and
educating providers about treatment options, with the goal of embedding
evidence-based care for alcohol related conditions into standard clinical
work. As in all health care organizations, considerable effort is required to
support providers in adopting evidence-based processes of care for tobacco and
alcohol screening and interventions. The strong evidence base for tobacco and
alcohol has been important in building this support among providers. We are
concerned that this combined measure (that includes processes of care that
lack evidence) will undermine our efforts in tobacco and alcohol.
3. Competing/perverse incentives for providers. The bundled measure requires
that all four processes of care be completed to receive credit. This could
create incentives for providers to focus on increasing their SBI rates for
prescription drug abuse and illicit drug use (which will be starting from very
low baseline rates), at the expense of continuing to improve SBI rates for
tobacco and alcohol use, which are likely to be higher, but still far from
ideal. The separate measures that already exist for SBI for tobacco use and
unhealthy alcohol use are preferable for this reason. 4. Lack of evidence for
a bundled measure. We need more data on the effect of bundling these measures
on processes of care in real world settings before implementation.
5. Reimbursement confusion. The combined measure also creates confusion
regarding reimbursement, since the tobacco and alcohol activities are
recommended by USPSTF and thus are reimbursable, whereas
screening/intervention for nonmedical prescription drug use and illicit drug
use are not. Note: These comments apply to MUC X3475, across all pertinent
programs: Medicare and Medicaid EHR Incentive Program for Eligible
Physicians; Medicare Physician Quality Reporting system/Physician Compare; and
Medicare Shared Savings References Roy-Byrne P, Bumgardner K, Krupski A, Dunn
C, Ries R, Donovan D, West, II, Maynard C, Atkins DC, Graves MC, Joesch JM,
Zarkin GA. Brief intervention for problem drug use in safety-net primary care
settings: a randomized clinical trial. JAMA. 2014;312(5):492-501. Saitz R,
Cheng DM, Allensworth-Davies D, Winter MR, Smith PC. The ability of single
screening questions for unhealthy alcohol and other drug use to identify
substance dependence in primary care. J Stud Alcohol Drugs.
2014;75(1):153-157. PMCID: PMC3893629. (Submitted by: Group
Health)
- [Pre-workgroup meeting comment] It is impossible to safely
prescribe medication to a patient without knowing if they are on illicit
drugs, or misusing prescription drugs. This measure will help address this
worsening epidemic.(Submitted by: University of Texas)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Plan)
- [Pre-workgroup meeting comment] I recommend the clinical quality
measure MUC ID X3475 substance screening and intervention composite for
inclusion in the CMS programs for which it is under consideration. Substance
use problems and illnesses have substantial impact on health and societal
costs, and often are linked to catastrophic personal consequences. Over 40
million adults in the United States demonstrate ìmedically harmful substance
useî which is less severe than full-blown addiction. This is a medical
condition in their own right, but when unaddressed in the treatment of other
medical illnesses produces: generally poor adherence to medications; poor
control of hypertension and diabetes; increased risk for a host of cancers and
medical illnesses; and decreased effectiveness of treatments for chronic pain.
More severe and chronic addictions exact a high toll in preventable death.
Importantly, prescription drug overdose is now the leading cause of accidental
death in the United States - surpassing motor vehicle accidents. Since
medically harmful substance use produces a wide variety of medical problems
and is an important contributor to years of life lost due to disability,
substance use disorders (SUD) are one of the 10 categories of essential health
benefits which the Patient Protection and Affordable Care Act requires most
private insurers to cover. Insurers also must ensure these benefits comply
with the Mental Health Parity and Addiction Equity Act. 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 (CDS) tools. Furthermore, if primary
care physicians do not screen for medically harmful drug use, guided by
pertinent performance measures in electronic health record systems to do so,
it will go undetected and likely confound patient-centered care. Recognizing
this urgent and unaddressed public health need, the National Quality Forum
(NQF) Behavioral Health Measures Standing Committee voted in October to
approve for trial use purposes (by a vote of 20 in favor to 2) the clinical
quality measure for substance screening and intervention composite, in the MAP
list of measures under consideration. For the reasons above, I encourage the
MAP to support this measure to be included in the CMS programs for which it is
being considered. Sincerely, Dr. Udi E. Ghitza (Submitted by: Dr. Udi E.
Ghitza)
- [Pre-workgroup meeting comment] I recommend the clinical quality
measure MUC ID X3475 substance use screening and intervention composite for
inclusion in the CMS programs for which it is under consideration. Substance
use problems and illnesses have substantial impact on health and societal
costs, and often are linked to catastrophic personal consequences. Over 40
million adults in the United States demonstrate ìmedically harmful substance
useî which is less severe than full-blown addiction. This is a medical
condition in their own right, but when unaddressed in the treatment of other
medical illnesses produces: generally poor adherence to medications; poor
control of hypertension and diabetes; increased risk for a host of cancers and
medical illnesses; and decreased effectiveness of treatments for chronic pain.
More severe and chronic addictions exact a high toll in preventable death.
Importantly, prescription drug overdose is now the leading cause of accidental
death in the United States - surpassing motor vehicle accidents. Since
medically harmful substance use produces a wide variety of medical problems
and is an important contributor to years of life lost due to disability,
substance use disorders (SUD) are one of the 10 categories of essential health
benefits which the Patient Protection and Affordable Care Act requires most
private insurers to cover. Insurers also must ensure these benefits comply
with the Mental Health Parity and Addiction Equity Act. 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 (CDS) tools. Furthermore, if primary
care physicians do not screen for medically harmful drug use, guided by
pertinent performance measures in electronic health record systems to do so,
it will go undetected and likely confound patient-centered care. Recognizing
this urgent and unaddressed public health need, the National Quality Forum
(NQF) Behavioral Health Measures Standing Committee voted in October to
approve for trial use purposes (by a vote of 20 in favor to 2) the clinical
quality measure for substance use screening and intervention composite, in the
MAP list of measures under consideration. For the reasons above, I encourage
the MAP to support this measure to be included in the CMS programs for which
it is being considered. Sincerely, Dr. Udi E. Ghitza (Submitted by: Dr. Udi E.
Ghitza)
- [Pre-workgroup meeting comment] Comments from the American Society
of Addiction Medicine December 5, 2014 Untreated substance use disorders
(SUDs) place individuals at significantly greater risk for a wide range of
diseases and are a significant public health burden, yet only one tenth of
Americans with SUDs received treatment in 2012. Screening and brief
intervention has been shown to be an effective tool for identifying and
treating substance use disorders in primary care settings. However, screening
and brief intervention remains an underutilized early intervention mechanism.
The Substance Use Screening and Intervention Composite Measure was submitted
to the NQF Behavioral Health Committee as a trial measure and was reviewed on
October 2. This measure is intended to assess the extent to which primary
care patients receive evidence-based screenings for potential misuse of
several categories of substances, including tobacco, alcohol, and licit and
illicit drugs. The measure assesses the percent of patients who are screened
for unhealthy tobacco, alcohol, and drug use and the percent that are offered
an intervention in response to a positive screen. The component measures
within the composite each look independently at the percent of patients
screened AND provided the brief intervention or counseling. The composite
then aggregates the component outcome data using an opportunity-based
composite scoring approach where each component contributes equally to the
composite outcome. As it was designed, the measure focuses on reporting and
monitoring of each component separately, while also giving an overall picture
of performance at the composite level. Composite measure benefits include
reducing the information burden by distilling the available indicators into a
simple summary, tracking a broader range of metrics than would be possible
otherwise, and making provider assessments more comprehensive. All the
components within the Substance Use Screening and Intervention Composite
Measure (alcohol, tobacco and drugs) are significant public health issues that
would benefit from the implementation of this measure. Furthermore, it
captures the tendency for polysubstance use among this patient population.
(Submitted by: American Society of Addiction Medicine)
- [Pre-workgroup meeting comment] I endorse this measure but with the
qualification that it not be enforced until the USPSTF issues a grade A or B
recommendation to implement it in routine primary care services. This service
currently carries a I statement (insufficient evidence). Although a single
brief intervention has not been found to be effective in RCTs of this service,
it is still important to screen for illicit and prescription drug misuse, and
for marijuana use in order to provide good patient care.(Submitted by: Peer
Assistance Services, Inc.)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3475) |
- I strongly support inclusion of this substance use screening and
intervention composite measure in the PQRS/Physician Compare/Physician
Feedback/VBPM program. Substance use disorders (SUDs) are a critical risk
factor for chronic medical illnesses and complication of their treatment, and
they should not be ignored. According to U.S. national surveys, SUDs marked by
hazardous use of alcohol, tobacco products, non-prescribed drugs and illicit
drugs affect approximately 20 percent of adult populations. Approximately 8
to 10 percent of adults have the most serious form of SUDs - addiction. An
additional 40 million adults use substances in a way that substantially
interferes with their health and healthcare. SUDs produce a wide variety of
medical problems and are important contributors to years of life lost due to
disability and preventable death. When unaddressed in the treatment of other
medical illnesses, SUDs generally produce poor adherence to medications; poor
control of hypertension and diabetes; increased risk for a host of cancers and
medical illnesses; increased risk for transmission of HIV and other sexually
transmitted diseases; and decreased effectiveness of treatments for chronic
pain. Furthermore, prescription drug overdose is now the leading cause of
accidental death in the United States - surpassing motor vehicle accidents.
Yet, screening, intervening, and treating SUDs have not been embraced within
primary care settings. In fact, even though untreated SUDs place individuals
at significantly greater risk for a wide range of diseases and are a
significant public health burden, only one tenth of Americans with SUDs
received treatment in 2013 partly due to gross under-screening and
intervention in primary care settings. This rendering of patients with
hazardous drug use as largely invisible in primary care settings is very
problematic in that it is impossible to safely prescribe medication to
patients without knowing if they are on illicit drugs, or misusing
prescription drugs. Further, if primary care physicians do not screen for
hazardous drug use, guided by pertinent clinical quality measures in
electronic health record systems to do so, it will go undetected or
under-detected and likely confound patient-centered care. This composite
measure will help address the worsening epidemic of medically harmful drug
use. Since SUDs produce a wide variety of medical problems, the Patient
Protection and Affordable Care Act requires most private insurers to expand
coverage and access to a range of care options for prevention, early
intervention, treatment and continuing management of substance use disorders.
Insurers also must ensure these benefits comply with the Mental Health Parity
and Addiction Equity Act. Consequently, it is necessary that health care
providers in general medical settings be equipped to become competent in
implementing and managing effective substance misuse prevention and treatment
interventions. One key means to enable this is for providers to be provided
appropriate training and resources to support and guide evidence-based
screening and intervention for SUDs in primary care settings, utilizing
relevant electronic-health-record-based clinical quality measures and
accompanying evidence-based, point-of-care clinical decision support (CDS)
tools. Since 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 hazardous substance use (and pharmacotherapy for tobacco use) has been
shown to be an effective intervention for reducing problem use in primary care
settings. In addition, for many patients presenting for primary care with
hazardous drug use, learning the consequences of their ìat riskî behavior or
abuse can provide a teachable moment and the wake-up call they need to either
stop using or seek appropriate follow-up treatment. All the components within
the Substance Use Screening and Intervention Composite Measure (tobacco use,
unhealthy alcohol use, illicit drug use, and non-medical prescription drug
use) are clinically significant public health issues that would benefit from
the implementation of this measure. This composite measure does not, however,
mitigate the importance of the individual component measures. In fact, the
component measures within this composite independently evaluate the percentage
of patients screened AND provided the intervention. The composite then
aggregates the component outcome data using an opportunity-based composite
scoring approach in which each component contributes equally and independently
to the composite outcome. Hence, this measure both focuses on reporting each
component separately and also reduces information burden by synthesizing
available metrics into a simple overall picture of performance at the
composite level. In this manner, this composite measure tracks a wider range
of indicators than would be otherwise possible in a comprehensive yet
parsimonious way. In summary, I support this measureís inclusion in this CMS
Program. There is an urgent public health need for such a clinical quality
measure be incorporated in electronic health record systems (EHR) and to
incentivize providers to systematic identify (currently grossly undetected)
patients with hazardous substance use in primary care settings, which is
necessary to support integrated care and to move patients with substance use
disorders into appropriate evidence-based prevention/treatment interventions
(including medication-assisted treatment). There is also an important need for
the high-value information captured in this composite measure to be recorded
in the EHR and linked to multiple aspects of clinical decision-making and
clinical decision support tools for appropriate interventions. Sincerely,
Dr. Udi E. Ghitza (Submitted by: Dr. Udi E. Ghitza)
- ASN does not support this measure and believes that this may be an
appropriate measure as a metric in the primary care setting but is not
suitable for dialysis facilities. As such, ASN agrees with NQF that this
measure should be fully developed before it comes up for
consideration.(Submitted by: American Society of Nephrology
(ASN))
- see incentive program comments. Particularly worrisome to use this
measure for physician practice feedback. (Submitted by: Boston Medical
Center/Boston University)
- I have reviewed the scientific evidence for the proposed Measure Under
Consideration (MUC) X3475: Substance Use Screening and Intervention Composite
(for tobacco use, alcohol use, illicit drug use and prescription drug abuse),
both as a scientist who assesses such clinical evidence (e.g., Chair, USPHS
Tobacco Cessation Clinical Practice Guideline Panels) and as a practicing
primary care physician. Based on this review, my conclusion is that the
illicit and prescription drug abuse components of MUC X3475 have insufficient
evidence for endorsement. Moreover, these measures would result in a
substantial and unsupported burden on primary care leading me to recommend
against endorsement. Specifically: 1) United States Preventive Services
Task Force Review (USPSTF): USPSTF has not endorsed illicit and prescription
drug screening and intervention. 2) Two key JAMA articles: Two recent
(8/6/14) JAMA articles (Saitz et al: Screening and brief intervention for drug
use in primary care: the ASPIRE randomized clinical trial + Roy-Byrne et al:
Brief intervention for problem drug use in safety-net primary care settings: a
randomized clinical trial) drew a consistent conclusion: "Brief intervention
did not have efficacy for decreasing unhealthy drug use in primary care
patients identified by screening.î 3) Accompanying JAMA Editorial: The
importance of these 2 articles was underscored by an accompanying NIH
editorial (Hingson and Compton: Screening and Brief Intervention and Referral
to Treatment for Drug Use in Primary Care - Back to the Drawing Board). The
title clearly states their conclusions. 4) NQF Evaluation of the Scientific
Evidence for MUC X3475: Several members of the NQF Measure Applications
Partnership (MAP) Clinician Work Group expressed significant concerns that the
two components of MUC X3475 relating to drug use are not evidence-based. The
MAP Clinician Work Group acknowledged the strong evidence base for tobacco and
alcohol screening and intervention. 5) Burden: The United States health
care system is under incredible stress - ACA, Meaningful Use, performance
measures, EHR implementation. How can we recommend universal adoption of a
complex and burdensome screening and intervention composite measure when we
don't have a consistent evidence base to support two components of it? In
conclusion, my review of the evidence is that MUC X3475 as it currently exists
is just not ready for endorsement and implementation. I think the composite
measure also poses a threat in terms of potentially undermining recommended
screening and brief interventions for the two major health risks for which
there is a powerful and consistent evidence base ñ tobacco and alcohol. More
evidence in the future might provide a compelling case for illegal and
prescription drug screening and intervention. But, at this point, we lack
such evidence to move forward with the illegal and prescription drug
components of MUC X3475. Michael Fiore, MD, MPH, MBA(Submitted by: University
of Wisconsin School of Medicine and Public Health Center for Tobacco Research
and Intervention)
- [Pre-workgroup meeting comment] Having worked in the field of
screening and brief intervention for over 25 years as a researcher and
consultant to SAMHSA and CDC, I have concerns with the composite measure
X3475. While the evidence for tobacco and alcohol screening and brief
intervention has been reviewed by the USPSTF and found sufficient to support
recommendations that these preventive services be used with adults in primary
care, the same cannot be said for nonmedical prescription drug use and illicit
drug use. Indeed, all the recently reported results of NIDA-funded studies
have failed to show the efficacy of this approach for such drugs. While it is
important that all medical services be supported by evidence, it is even more
critical that new preventive services have good evidence of efficacy as
determined by the USPSTF. Therefore, I strongly recommend that you approve
measure E2152. If, however, you decide to approve X3475 I hope it will contain
a condition that implementation of the component for nonmedical prescription
drug and illicit drug use be postponed until the USPSTF issues a B
recommendation or better for these services, showing that there is sufficient
evidence to support the measures. John C. Higgins-Biddle, Ph.D.
johnhb7@comcast.net(Submitted by: University of Connecticut School of
Medicine, Retired)
- [Pre-workgroup meeting comment] I am Medical Director for
Preventive Care at Group Health (GH), an integrated delivery system and health
plan that serves almost 600,000 members in Washington and Idaho. I am writing
to you to express GHís concern about this measure on the annual CMS Measures
Under Consideration (MUC) list. This measure combines screening and
intervention for tobacco use, unhealthy alcohol use, nonmedical prescription
drug use, and illicit drug use. GH is concerned that the proposed measure
combines both evidence-based processes of care (screening and brief
intervention (SBI) for tobacco use and unhealthy alcohol use) and
non-evidence-based (SBI for prescription drug abuse and illicit drug use)
processes of care into a single bundled measure. Our concerns revolve around
these issues: 1. Lack of evidence for screening for substance use disorders.
While population-based substance use screening has great potential merit, no
rigorous study has examined the impact of substance use screening and
assessment for substance use disorders, compared to usual care without
screening. In fact, two recent trials comparing screening and BI to screening
without BI found no added effects (Roy-Byrne et al, 2014 and Saitz et al,
2014). Our research team at the Group Health Research Institute, led by Dr.
Katharine Bradley, is engaged in research efforts to develop ways address
screening for drug use and ensure that identified individuals benefit from
treatment. 2. Impact of bundling on provider engagement in tobacco and alcohol
processes of care. GH has been a leader in tobacco screening and
intervention, and we have worked hard to embed these processes into clinical
care. Our ongoing work in the area of alcohol screening and intervention is
aimed in part at breaking down providersí misconceptions about alcohol use and
educating providers about treatment options, with the goal of embedding
evidence-based care for alcohol related conditions into standard clinical
work. As in all health care organizations, considerable effort is required to
support providers in adopting evidence-based processes of care for tobacco and
alcohol screening and interventions. The strong evidence base for tobacco and
alcohol has been important in building this support among providers. We are
concerned that this combined measure (that includes processes of care that
lack evidence) will undermine our efforts in tobacco and alcohol.
3. Competing/perverse incentives for providers. The bundled measure requires
that all four processes of care be completed to receive credit. This could
create incentives for providers to focus on increasing their SBI rates for
prescription drug abuse and illicit drug use (which will be starting from very
low baseline rates), at the expense of continuing to improve SBI rates for
tobacco and alcohol use, which are likely to be higher, but still far from
ideal. The separate measures that already exist for SBI for tobacco use and
unhealthy alcohol use are preferable for this reason. 4. Lack of evidence for
a bundled measure. We need more data on the effect of bundling these measures
on processes of care in real world settings before implementation.
5. Reimbursement confusion. The combined measure also creates confusion
regarding reimbursement, since the tobacco and alcohol activities are
recommended by USPSTF and thus are reimbursable, whereas
screening/intervention for nonmedical prescription drug use and illicit drug
use are not. Note: These comments apply to MUC X3475, across all pertinent
programs: Medicare and Medicaid EHR Incentive Program for Eligible
Physicians; Medicare Physician Quality Reporting system/Physician Compare; and
Medicare Shared Savings References Roy-Byrne P, Bumgardner K, Krupski A, Dunn
C, Ries R, Donovan D, West, II, Maynard C, Atkins DC, Graves MC, Joesch JM,
Zarkin GA. Brief intervention for problem drug use in safety-net primary care
settings: a randomized clinical trial. JAMA. 2014;312(5):492-501. Saitz R,
Cheng DM, Allensworth-Davies D, Winter MR, Smith PC. The ability of single
screening questions for unhealthy alcohol and other drug use to identify
substance dependence in primary care. J Stud Alcohol Drugs.
2014;75(1):153-157. PMCID: PMC3893629. (Submitted by: Group
Health)
- [Pre-workgroup meeting comment] Physicians who prescribe medication
and offer medical and surgical treatments without knowing whether their
patient smokes, uses drugs, or uses alcohol in excessive amounts are
practicing in a manner that is equivalent to not screening for blood sugar or
hypertension. Substance use is a critical risk factor, and it should not be
ignored when doing so is practicing sub-standard medicine.(Submitted by:
University of Texas)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Plan)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Plan)
- [Pre-workgroup meeting comment] I strongly support use of this
measure. Recent JAMA studies finding drug interventions ineffective focused
only on severely disadvantaged patients. This metric would only be a first
step in the right direction, as it will not reflect the quality of the
intervention. Mere brief advice would satisfy the metric but not elicit the
behavior change and the cost savings obtained in prior RCTs.(Submitted by:
Wisconsin Initiative to Promote Healthy Lifestyles)
- [Pre-workgroup meeting comment] I strongly support use of this
measure. Recent JAMA studies finding drug interventions ineffective focused
only on severely disadvantaged patients. This metric would only be a first
step in the right direction, as it will not reflect the quality of the
intervention. Mere brief advice would satisfy the metric but not elicit the
behavior change and the cost savings obtained in prior RCTs.(Submitted by:
Wisconsin Initiative to Promote Healthy Lifestyles)
- [Pre-workgroup meeting comment] Comments from the American Society
of Addiction Medicine December 5, 2014 Untreated substance use disorders
(SUDs) place individuals at significantly greater risk for a wide range of
diseases and are a significant public health burden, yet only one tenth of
Americans with SUDs received treatment in 2012. Screening and brief
intervention has been shown to be an effective tool for identifying and
treating substance use disorders in primary care settings. However, screening
and brief intervention remains an underutilized early intervention mechanism.
The Substance Use Screening and Intervention Composite Measure was submitted
to the NQF Behavioral Health Committee as a trial measure and was reviewed on
October 2. This measure is intended to assess the extent to which primary
care patients receive evidence-based screenings for potential misuse of
several categories of substances, including tobacco, alcohol, and licit and
illicit drugs. The measure assesses the percent of patients who are screened
for unhealthy tobacco, alcohol, and drug use and the percent that are offered
an intervention in response to a positive screen. The component measures
within the composite each look independently at the percent of patients
screened AND provided the brief intervention or counselling. The composite
then aggregates the component outcome data using an opportunity-based
composite scoring approach where each component contributes equally to the
composite outcome. As it was designed, the measure focuses on reporting and
monitoring of each component separately, while also giving an overall picture
of performance at the composite level. Composite measure benefits include
reducing the information burden by distilling the available indicators into a
simple summary, tracking a broader range of metrics than would be possible
otherwise, and making provider assessments more comprehensive. All the
components within the Substance Use Screening and Intervention Composite
Measure (alcohol, tobacco and drugs) are significant public health issues that
would benefit from the implementation of this measure. Furthermore, it
captures the tendency for polysubstance use among this patient population.
(Submitted by: American Society of Addiction Medicine)
- [Pre-workgroup meeting comment] ASN does not support this measure
and believes that this may be an appropriate measure as a metric in the
primary care setting but is not suitable for dialysis facilities.(Submitted
by: American Society of Nephrology (ASN))
- [Pre-workgroup meeting comment] I do not support Substance Abuse
Screening and Intervention Composite MUC ID X3475. Both NQF and CDC do not
support. Insufficient evidence. (Submitted by: School of Public Health
University of Illinois at Chicago )
| (Program: Medicare Shared Savings
Program; MUC ID: X3476) |
- See full comments.We are opposed to the use of this measure for any
program orpatient population. (Submitted by: SMT, Inc)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare and Medicaid EHR
Incentive Programs for Eligible Professionals; MUC ID: X3476)
|
- We are opposed to this performance measure as it is written. We do not
believe it is based on evidence that an A1c of <7% poses a greater threat
of harm than benefit for all patients with diabetes when they reach 65. We
have greater concern about its negative effect on patient care. The Medicare
beneficiary trusts that performance measures adopted by Medicare represent
high quality care and will not put them at unnecessary risk of harm. To adopt
this measure, CMS is telling beneficiaries that it is not only safe for them
to let their A1c go up, it is riskier and the potential for harm is greater if
they keep it at or below 7%. Based on the clinical studies, this position
puts the entire population at risk for developing and increasing the
progression of microvascular and macrovascular complication, which could be
avoided with better glycemic control. This will impact a significant number
of beneficiaries. More of those over 65 have been in good control as compared
to younger patients. Hoerger reported that 68.3% of those over 65 had an A1c
<7% in 2004., an increase over the 36% in 2000 and 56% in 2004.
(Hoerger.Diabetes Care 2008) Menzin reported that out of 5600 patients with an
A1c <7%, 68% were over 65. Of the 6200 patients over 65, 62% had an A1c
< 7%. (Menzin J. 2010: 263:275) These numbers would suggest that those
over 65 are interested and able to achieve good control, without harm. One
unintended consequence for the clinics if those over 65 were removed from the
other quality measure specifications, clinics may be surprised to find their
scores on control <7% for HEDIS will drop because they have removed those
most successful at achieving good glycemic control. There are 2 aspects to an
analysis and final recommendations for a performance measure: the risks and
the benefits of an A1c <7% and the risk/benefits of having a higher A1c.
As the MAP recommendation notes, the evidence and guidelines recommends a
less aggressive target in a subset of the patients with diabetes based on an
increase risk associated with a lower A1c (e.g. A1c target of >7%).
Specifically those patients are identified at higher risk of harm are those
having ëa long duration of diabetes, known history of severe hypoglycemia,
advanced atherosclerosis, or advanced age/frailtyí (ADA Standards , Diabetes
Care. Chapter 5. Jan2015). These are the only people considered by the
guidelines to be at increased risk with a target of 7%; they are the only
people for whom a measure addressing overtreatment and increased risk should
be applied. For all others, the ADA Standards identify numerous studies that
demonstrate the benefit of good glycemic control starting with the reduction
in microvascular events (retinal and neuropathy). The 3 landmark studies
(ACCORD, ADVANCE and VADT) started with older patients who had a longer
history of diabetes and they showed that the lower A1C levels were associated
with either a reduced onset of microvascular complications and/or a slowing of
their progression. These studies are of special interest because the patient
populations were older, closer to the 65 yrs identified in this measure. In
ACCORD, intensive therapy was still favored over an Ac1 of 7.0-7.9% in those
65 an older with 4-year follow-up. (ACCORD NEJM 2010: pp 233-244) The second
consideration in use of a performance measure is the balance between benefit
and harm with the clinical changes associated with the measure, specifically;
encouraging patients over 65 to have an A1c over 7%. We will start with the
potential for harm first which is not addressed in the rationale given for
this measure. The harm would be onset and/or progression of microvascular and
macrovascular complications associated with higher A1c scores. For those who
are not defined as ëat riskí by the guidelines, there is no evidence that
benefit from good control especially for microvascular complications stops at
age 65 or no longer matters In the 2008 and 2009 ADA guidelines, they
specifically stated that for those who were ëfunctional, cognitively intact
and have a significant life expectancyí, their diabetes treatment should use
goals developed for younger persons. The complications and their progression
do not have an age cut-off, there is increased progression of complications
for those with higher A1c scores. If we want to find evidence of harm
associated with increasing A1c levels, we need only look at the experience of
the control patients in the studies. The 3 landmark studies (ACCORD, ADVANCE
and VADT) started with older patients who had a longer history of diabetes.
(Ismail-Beigi 2010:419-430, Patel 2008:1560-2572; Duckworth 2009: 129-139)
They showed that lower A1C levels were associated with either a reduced onset
of microvascular complications and/or a slowing of their progression. If we
are considering the potential for harm, we would look at the experience of the
control groups in the clinical studies. These studies are of special interest
because the patient populations were older, closer to the 65 yrs identified in
this measure. In ACCORD, intensive therapy was still favored in those 65 an
older. The ADVANCE study involved patients 66 years on over who had a
diagnosis for 8 years. The difference in A1c levels was 6.5% in the study
group and 7.3% in the control group. Even with this low of an A1c in the
control group, at 5 years there was a 22% relative reduction in the risk of
new or worsening of nephropathy in the intensive group. Because
complications increase with higher A1c levels, the potential for major harm to
the Medicare beneficiary over 65 who allows their A1c to increase based on
this proposed measure is very significant. For the person with diabetes who
is 65 and older, if better control reduces onset/progression, then they can
expect that if they allow their A1c to increase above 7%, their experience
will be similar to the study control groups, which these studies and others
have shown experience an increase in complications or their progression.
Menzinís analysis of the relationship between glycemic control,
hospitalization and costs showed an increased proportion of hospitalization
among those with an A1c of 8% or greater and an increase in hospitalization
rate starting with an A1c of 708%. (Menzin 2010: 264-275)The UKPDS results
were significant for the impact on progression of DR, even when the median
difference in A1c between the study groups was 0.9%.(Kohner 2008:Suppl2:20-24)
There was a 31% lower risk of retinopathy for a 1% decrease in A1c. This
was thought to occur regardless of the initial level of retinopathy. There was
also a 19% reduced risk of cataract extraction for each 1% decrement in A1c.
For those who had evidence of retinopathy at baseline, progression was
associated with older age, male sex and higher A1c.(Stratton, 2001:156-63)
Progression of retinopathy is significant as measured in 1 and 3 year
increments, which are very pertinent to a person 65 and over. It is not
measured in 10-15 year results.(Lee LJ, 2008:1549-159, Shea AM et al,
2008:1748-1754.) In short, we believe this draft performance measure is not
consistent with the guideline recommendations for the population at risk of
harm from an A1c of 7.0%. With an over-inclusive patient population, it puts
all other patients at risk of harm from progression of microvascular and
macrovascular complications, increased hospitalization and overall increased
health care utilization and decreased quality of life associated with
retinopathy, neuropathy and CKD. We are totally opposed to this measure.
(Submitted by: SMT,Inc)
- There is no evidence in elderly populations. Need a cut off age of
75.(Submitted by: Armstrong Instititue for Patient Safety and
Quality)
- The measure proposes to raise HbA1c targets among patients 65 years of age
and older, particularly due to concern of hypoglycemia in older adults. We
acknowledge that the American Diabetes Association (ADA) recommends
individualized HbA1c targets, including less stringent approaches to the
management of hyperglycemia among patients with risk of hypoglycemia,
long-standing diabetes, short life-expectancy, and severe comorbidities.
Nevertheless, we recommend against adoption of this measure because at a
population level it may negatively impact care for elderly patients with type
2 diabetes mellitus (T2DM). The American Diabetes Association (ADA) position
statement and the 2013 consensus statement from ADA and The Endocrine
Society, acknowledge that the elderly are, ìparticularly vulnerable to
hypoglycemia due to their limited ability to recognize hypoglycemic symptoms
and effectively communicate their needs.î The report then recommends many
strategies to manage elderly patients with T2DM and improve patient outcomes:
avoid sliding scale insulin, avoid complex regimens, individualize patient
education, dietary intervention, exercise management, medication adjustment,
glucose monitoring, and routine clinical surveillance. At a population level,
raising HbA1c quality measure targets among elderly patients with T2DM could
remove the incentive to provide appropriate, holistic treatment of a patientís
T2DM through these, and other strategies, and ultimately do a disservice to
elderly patients. Importantly, according to the American Association of
Clinical Endocrinologists (AACE) 2013 Comprehensive Diabetes Management
Algorithm of the 11 classes of medications available for the treatment of
T2DM, just 3 classes (insulin, sulfonylureas, and meglitinides/glinides) have
an increased risk of hypoglycemia . The modern therapeutic armamentarium
offers many elderly patients with T2DM the ability to reach an HbA1c goal of
less than 7% without an excessive risk of hypoglycemia. Finally, we are
concerned about how the measure would be technically assessed. Would the
measure penalize providers and plans for rates of elderly patients with T2DM
with HbA1c values of <7%? Possibly embedded in the measure would be a
disincentive to worsen the HbA1c of patients in relatively good control by
encouraging well-controlled patients without hypogycemia to reverse course.
For these reasons, we recommend against any further consideration of this
measure, but continue to endorse the minimization of hypoglycemia. i.
Standards of Medical Care in Diabetes ñ 2014. American Diabetes Assocation.
Diabetes Care. Volume 37, Supplement 1, January 2014. ii. Standards of
Medical Care in Diabetes ñ 2014. American Diabetes Assocation. Diabetes
Care. Volume 37, Supplement 1, January 2014. iii. Garber et al. AACE
Comprehensive Diabetes Management Algorithm 2013. iv. (a) Zhang Y, Wieffer
H, Modha R, et al. The burden of hypoglycemia in type 2 diabetes: a systematic
review of patient and economic perspectives. JCOM 2010;17:547-557.(b) Geller
AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related
hypoglycemia and errors leading to emergency department visits and
hospitalizations. JAMA Intern Med. doi:10.1001/jamainternmed.2014.136.
Published online March 10, 2014. (c) Budnitz DS, Lovegrove MC, Shehab N, et
al. Emergency hospitalizations for adverse drug events in older Americans.
NEJM 2011;365:2002-2012. (Submitted by: AstraZeneca
Pharmaceuticals)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] Treating physicians need to be
guided by their medical judgment and the patientís goals and health status
(M.S. Kirkman et al., ìDiabetes in Older Adults: A Consensus Report,î Journal
of the American Geriatrics Society, Special Report, 2012 at page 9). What is
an appropriate level of control for an otherwise healthy 80-year-old with T1
or T2 diabetes may differ considerably from a 70-year-old diabetic patient
with a predisposition to hypoglycemia or comorbidities. ìIn patients with
T2DM [Type 2 Diabetes Mellitus], achieving the glucose target and hemoglobin
A1C (A1C) goal requires a nuanced approach that balances age, comorbidities,
and hypoglycemia risk. The AACE [American Association of Clinical
Endocrinologists] supports an A1C goal of =6.5% for most patients and a goal
of >6.5% if the lower target cannot be achieved without adverse outcomes
(Comprehensive Diabetes Management Algorithm - Goals for Glycemic Control in
ìAACE Comprehensive Diabetes Management Algorithm 2013 Endocrine Practice,î J.
Endocr. Pract. 2013; 19 (Suppl. 2) at p. 4.) SMT believes that for the MAP to
recommend MUC ID X3476 for inclusion by CMS in the Medicare programís quality
measures would be misguided. Although the measure may reflect a
widely-accepted consensus about appropriate HbA1c levels in general, it is not
consistent with widely-accepted treatment goals for many individual diabetic
patients (Comprehensive Diabetes Management Algorithm - Goals for Glycemic
Control in ìAACE Comprehensive Diabetes Management Algorithm 2013 Endocrine
Practice,î J. Endocr. Pract. 2013; 19 (Suppl. 2) at p. 4.) If assessing
quality of their care is overly generalized into average, age-grouped targets
in the Medicare patient population, the focus on individual treatment and
desirable health care outcomes is diminished and could be detrimental to
Medicare patients (Gavin, J.R. et al. Improving Outcomes in Patients With Type
2 Diabetes Mellitus: Practical Solutions for Clinical Challenges, JAOA, Vol.
110, No 5; Suppl. 6, May 2010). HbA1c is the most important single measure
in diabetes treatment and indicator of blood sugar control; and optimal
control of blood glucose is the cornerstone of diabetes patient care
management (Gavin, J.R. et al. Improving Outcomes in Patients With Type 2
Diabetes Mellitus: Practical Solutions for Clinical Challenges, JAOA, Vol.
110, No 5; Suppl. 6, May 2010) The rationale for this measure focuses only
on the evidence related to cardiovascular disease. It also assumes the
patients will not live long enough to experience the positive effects of good
glycemic control. If a person has achieved good control of their diabetes
prior to turning 65 without experiencing hypoglycemic or other harmful
effects, there is absolutely no reason to tell them they now should loosen
their control just because they turned a certain age. They continue to be
concerned about reducing their chance of developing complications and in
reducing their severity if at all possible. If good control prior to 65
results in a reduction in amputations rates (Health Partners experience), the
person who is now 65 is just as interested in continuing to maintain good
control and not develop PVD or undergo an amputation. Historically, more of
those over 65 have been in good control as compared to younger patients.
Menzin 2010 reported that out of 5600 patient who had an A1c <7%, 68% were
65 and over. This number would suggest that those over 65 are interested and
able to achieve good control, without harm. The evidence suggests that there
are some patients for whom this is not the appropriate goal. They have defined
in the ADA guidelines and are included in the rationale for this measure. For
those without those characteristics, there is no evidence that they no longer
benefit from good control especially for microvascular complications. We
would disagree with the statement about the timeline to microvascular
complications. The timeline to development and progression of microvascular
complications is significantly shorter than for CV. This measure does not
consider the evidence that A1c control affects the risk of developing
microvascular complications as well as affects the progression of the
complications, specifically ophthalmologic, peripheral vascular disease and
amputations, neuropathy and nephropathy. The ADVANCE study involved patients
66 years on aver who had a diagnosis for 8 years. Even in this population, at
5 years there was a 22% relative reduction in the risk of new or worsening of
nephropathy in the intensive group. The UKPDS results were significant for
the impact on progression of DR, even when the median difference in A1c
between the study groups was 0.9%.(Kohner 2008:Suppl2:20-24) There was a
31% lower risk of retinopathy for a 1% decrease in A1c. This was thought to
occur regardless of the initial level of retinopathy. There was also a 19%
reduced risk of cataract extraction for each 1% decrement in A1c. For those
who had evidence of retinopathy at baseline, progression was associated with
older age, male sex and higher A1c.(Stratton, 2001:156-63) Progression of
retinopathy is significant as measured in 1 and 3 year increments.(Lee LJ,
2008:1549-159, Shea AM et al, 2008:1748-1754.) Schellhase et al found a 25%
increased risk of second complication associated with each 1-percentage point
increase in HbA1c over a 3.7 year follow up. (Schellhase 2005:125-130)
(Submitted by: SMT, Inc.)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3476) |
- The full description and justification for the X3476 measure (Diabetes:
Hemoglobin A1c Overtreatment in the Elderly) was not available to us, but
based upon the information within the CMS Measures under Consideration and the
MAP reports, we offer the following comment: We support the increased
attention on hypoglycemia as a preventable outcome in diabetes, especially for
the elderly, However, there may be unintended negative consequences in
applying measure X3476 across all elderly patients where some individuals may
benefit from lower HbA1c levels,. American Diabetes Association (ADA)
guidelines identify HbA1c <7% as the target treatment threshold, and
emphasize the importance of individualization of care including glycemic
control based on unique patient circumstances. After careful consideration of
the potential risks and benefits, patients and their healthcare providers may
opt (ideally through shared decision making) for more aggressive glycemic
control. If hypoglycemia is of particular concern, using a measure focused
on minimizing hypoglycemic events could be warranted. (Submitted by: Johnson
& Johnson Health Care systems )
- See other full comments. We are opposed to this measure for any patient
population or program. (Submitted by: SMT, Inc)
- SHM agrees in general with the MAPís recommendation that this measure
should have continued development, but notes that this clinical area would
benefit from a complementary measure for hypoglycemia in the hospital and for
hospital-based physicians.(Submitted by: Society of Hospital
Medicine)
- Given the difficulties with the accuracy of Hemoglobin A1c in individuals
with advanced chronic kidney disease and, particularly, in those treated with
dialysis, ASN does not support this measure and agrees with NQF that this
measure should continue to be developed before it is reconsidered. There are
substantial data showing that HbA1c underestimates glycemic control in the
advanced kidney disease population, likely due to more rapid red blood cell
turnover. Please see Chen et al, Am J Kidney Dis 2010 for non-dialysis CKD
and Freedman et al, Perit Dial Int 2010 and Peacock et al, Kidney Int 2008 for
dialysis patient data. Therefore, we have concerns about the validity of the
measure in this population.(Submitted by: American Society of Nephrology
(ASN))
- Novo Nordisk, Inc. (ìNovo Nordiskî) appreciates the opportunity to provide
comments on MAPís 2014-2015 preliminary recommendations. Novo Nordisk applauds
MAP in its efforts to prioritize patient safety for diabetes patients through
the continued development of X3476 Diabetes: Hemoglobin A1c Overtreatment in
the Elderly. The American Diabetes Association (ADA) recently acknowledged
that less stringent A1C goals (other than < 7%) are appropriate for high
risk populations in its 2015 Standards for Diabetes Care (Reference: 2015
Standards for Diabetes Care), recommending that higher A1C goals (such as 8%)
may be appropriate for patients with limited life expectancy, comorbid
conditions, or long-standing diabetes. Novo Nordisk supports MAPís
suggested modification of this measure, but requests it be broadened to
include a denominator exclusion for all antihyperglycemic medications whose
mechanism of action is not known to cause hypoglycemia (metformin, SLGT-2
inhibitors, DPP-IV inhibitors, GLP1 Receptor Agonists). Furthermore, Novo
Nordisk requests that MAP consider any potential unintended consequences of
this measure that may arise from the under-treatment of diabetes patients as a
result of this measure. The benefits of use of this measure, which include
reducing rates of hypoglycemia and related complications, should be weighed
against the negative impacts of this measure, which may include encouraging
providers to undertreat elderly diabetic patients to ensure measure
compliance. Under-treatment of elderly diabetes patients may lead to poor A1C
control, which is associated with diabetes complications including mortality,
loss of vision or hearing, and amputation. The ADAís recommendation
acknowledges that multiple factors should be taken into consideration when
selecting A1C targets for a defined patient population; indicating that a
broad A1C outcome measure for the elderly population may not be appropriate.
Reference: 1. American Diabetes Association. Standards of medical care in
diabetesó2015. Diabetes Care. 2015; 38. (Submitted by: Novo
Nordisk)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] Given the difficulties with the
accuracy of Hemoglobin A1c in individuals with advanced chronic kidney disease
and, particularly, in those treated with hemodialysis, ASN does not support
this measure. There are substantial data showing that HbA1c underestimates
glycemic control in the advanced kidney disease population, likely due to more
rapid red blood cell turnover. Please see Chen et al, Am J Kidney Dis 2010 for
non-dialysis CKD and Freedman et al, Perit Dial Int 2010 and Peacock et al,
Kidney Int 2008 for dialysis patient data. Therefore, we have concerns about
the validity of the measure in this population.(Submitted by: American Society
of Nephrology (ASN))
| (Program: Medicare Shared Savings Program; MUC ID: X3481)
|
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
| (Program: Medicare Shared Savings Program; MUC ID: X3482)
|
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- We support the MAP preliminary recommendation but would also note the
following concern. It is difficult to assess how the measure will calculate
performance on Patient-reported Outcomes (PRO) due to the lack of detail
provided. Information on the various points in the process such as when
change is assessed and why an average across the patients was selected is
needed in order to adequately assess this measure. Because PRO measures are
not yet in wide use, CMS should test the measures for reliability and
validity. In addition, understanding attribution and how the
Measure-Applicability Validation will occur for these measures will be
critical prior to implementation in a pay-for-reporting or performance
program(Submitted by: American Medical Association)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3482) |
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- We support the MAP preliminary recommendation but would also note the
following concern. It is difficult to assess how the measure will calculate
performance on Patient-reported Outcomes (PRO) due to the lack of detail
provided. Information on the various points in the process such as when
change is assessed and why an average across the patients was selected is
needed in order to adequately assess this measure. Because PRO measures are
not yet in wide use, CMS should test the measures for reliability and
validity. In addition, understanding attribution and how the
Measure-Applicability Validation will occur for these measures will be
critical prior to implementation in a pay-for-reporting or performance
program.(Submitted by: American Medical Association)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3482)
|
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- We support the MAP preliminary recommendation but would also note the
following concern. It is difficult to assess how the measure will calculate
performance on Patient-reported Outcomes (PRO) due to the lack of detail
provided. Information on the various points in the process such as when
change is assessed and why an average across the patients was selected is
needed in order to adequately assess this measure. Because PRO measures are
not yet in wide use, CMS should test the measures for reliability and
validity. In addition, understanding attribution and how the
Measure-Applicability Validation will occur for these measures will be
critical prior to implementation in a pay-for-reporting or performance
program.(Submitted by: American Medical Association)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Medicare Shared Savings Program; MUC ID: X3483)
|
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3483) |
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3483)
|
- We support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. (Submitted by:
AdvaMed)
- We support this measure because it promotes outcomes-based,
patient-centered care.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
support this measure, provided that more specific and validated joint
arthroplasty tools for patient reported outcomes are used. We wanted to
highlight some specific knee and hip patient reporting tools that we could use
for measures X3482 and X3483: For both hip and knee: the Forgotten Joint
Score (FJS) and the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee: Knee Society Score (KSS) Hip: the International Hip
Outcome Score (iHOT) and the Harris Hip Score (HHS) (Submitted by:
AdvaMed)
| (Program: Medicare Shared Savings Program; MUC ID: X3485)
|
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3485) |
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3485)
|
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings Program; MUC ID: X3512)
|
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3512) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3512)
|
- ASN agrees with NQF that measure X3512 and X3816 should be fully developed
before these measures are reconsidered. ASN notes a discrepancy between these
proposed measures (X3512 and X3816) and the current Conditions for Coverage,
which, in 2008, specified an exemption for hepatitis C screening, since
Medicare only covers diagnostic hepatitis C testing when indicated and does
not cover general screening for hepatitis C. The CDC recommends assessing
Hepatitis C serologies in order to detect an outbreak of Hepatitis C, not in
order to treat Hepatitis C. If the intent of these proposed measures is to
encourage treatment of Hepatitis C, as they seem to be, ASN suggests that this
metric may be premature, pending further research into the efficacy, safety
and utility of treatment of Hepatitis C in dialysis patients, particularly in
those patients unlikely to receive kidney transplants and those without other
evidence of liver disease. (Submitted by: American Society of Nephrology
(ASN))
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment. We would like to share a minor correction to the listing of this
measure. The steward is listed as the American Medical Association. We would
prefer the listing to reference the American Medical Association-convened
Physician Consortium for Performance Improvement (AMA-PCPI), consistent with
other AMA-PCPI stewarded measures on the list. (Submitted by: American
Medical Association-convened Physician Consortium for Performance
Improvement)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] ASN suggests that regulations and
metrics remain aligned and, given current regulations, notes a discrepancy
between these proposed measures (X3512 and X3816) and the current Conditions
for Coverage, which, in 2008, specified an exemption for hepatitis C
screening, since Medicare only covers diagnostic hepatitis C testing when
indicated and does not cover general screening for hepatitis C. The CDC
recommends assessing Hepatitis C serologies in order to detect an outbreak of
Hepatitis C, not in order to treat Hepatitis C. If the intent of these
proposed measures is to encourage treatment of Hepatitis C, as they seem to
be, ASN suggests that this metric may be premature, pending further research
into the efficacy, safety and utility of treatment of Hepatitis C in dialysis
patients, particularly in those patients unlikely to receive kidney
transplants and those without other evidence of liver disease.(Submitted by:
American Society of Nephrology (ASN))
| (Program: Medicare Shared Savings Program; MUC ID: X3513)
|
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
| (Program: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals; MUC ID: X3513) |
- Would support this measure now.(Submitted by: Armstrong Instititue for
Patient Safety and Quality)
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment. We would like to share a minor correction to the listing of this
measure. The steward is listed as the American Medical Association. We would
prefer the listing to reference the American Medical Association-convened
Physician Consortium for Performance Improvement (AMA-PCPI), consistent with
other AMA-PCPI stewarded measures on the list. (Submitted by: American
Medical Association-convened Physician Consortium for Performance Improvement
)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3523) |
- The American College of Radiology supports this measure as
recommended.(Submitted by: American COllege of Radiology)
| (Program: Inpatient Quality Reporting Program ; MUC ID: X3620)
|
- Edwards supports the MAP recommendation to conditionally support
inclusion of this cost/resource use measure in the Hospital Inpatient Quality
Reporting program, pending NQF review to ensure the measure is scientifically
sound for use for national public reporting and accountability programs.
Edwards supports efforts to specifically address both the cost of and quality
of care when selecting measures for inclusion in CMS programs. Reporting this
measure with an indicator of quality of care associated with total hip and/or
total knee arthroplasty, such as functional status, will increase
understanding of the value of healthcare services provided, while also
illuminating drivers of cost. Furthermore, by incentivizing hospitals to
control costs for the THA/TKA episode of care, this measure will likely drive
improved care during the admission through utilization of evidence-based
practices to enhance recovery, as well as improved care coordination to
decrease readmissions and increase patient utilization of less costly
outpatient care.(Submitted by: Edwards Lifeciences)
- At this time we are not in favor of using this measure in the Hospital
Inpatient Quality Reporting. It appears that CMS has not yet had the
opportunity to consider the comments that were recently submitted on the
measure. We would like to consider this measure once CMS makes any revisions
to the draft measure.(Submitted by: AdvaMed)
- [Pre-workgroup meeting comment] We are not in favor of using this
measure in the Hospital Inpatient Quality Reporting. It appears that CMS has
not yet had the opportunity to consider the comments that were recently
submitted on the measure. We would like to consider this measure once CMS
makes any revisions to the draft measure.(Submitted by:
AdvaMed)
| (Program: PPS-Exempt Cancer
Hospital Quality Reporting Program ; MUC ID: X3629) |
- Position: Adopt this measure. Relevance: Unnecessary hospital
readmissions for cancer patients reduce their quality of life, place them at
risk for HAI, and increase healthcare spending. Preventing these readmissions
improves quality of care at the Cancer Centers. This measure was developed
specifically for cancer patients, who are excluded from 1789-Hospital-Wide
All-Cause Unplanned Readmission Measure (HWR). Likewise, the PCHs are excluded
from the HWR. The adoption of X3629-30-Day Unplanned Readmissions for Cancer
Patients for the PCHQR promotes meaningful comparisons between PCHs and is an
example of appropriate alignment between CMS quality programs. Usability:
Routine measurement of unplanned readmissions across the Cancer Centers will
allow for improvements in care coordination and quality improvement efforts to
drive reductions in these values. Because the Cancer Centers only care for
cancer patients, a more sensitive measure that is specific to cancer will help
us to direct our efforts to addressing truly preventable readmissions, thereby
improving our quality of care. No other measures in the PCHQR program address
this aspect of patient care. Feasibility: PCHs are capable of reporting this
measure according to the current specifications. (Submitted by: Alliance of
Dedicated Cancer Centers)
- To more accurately assess readmission patterns in cancer patients, it
would be useful to focus on just on cancer-related readmissions. As this
population frequently has multiple comorbidities in addition to a cancer
diagnosis, the draft measure definition could provide an inaccurate assessment
of cancer-related care, as readmissions due to co-morbidities would be also be
measured. The title of the measures uses ìunscheduledî readmissions, when
other endorsed measures exist that use the term ìunplannedî readmissions. If
appropriate, this terminology should be aligned. Also, does the title need to
include both ìUnscheduledî and ìpotentially avoidable?î It seems a currently
endorsed measured in this area only uses ìunplannedî in the title. (Submitted
by: Johnson & Johnson Health Care Systems Inc.)
- We thank the Measure Applications Partnership Coordinating Committee for
the opportunity to provide comments on their 2014-2015 Preliminary
Recommendations for measures under consideration. We agree with the MAP that
this is a critically important area for measurement and can help drive
alignment across health care facilities. There are many causes of unplanned
readmissions for cancer patients, one of which is Clostridium difficile
infection (CDI). Cancer patients are at particularly high risk for new and
recurrent CDI, have lower CDI cure rates, a longer time to resolution of
diarrhea, experience delays in receipt of chemotherapy or radiation treatment,
have prolonged hospitalization, and experience higher fatality rates.1-5 It
is for these reasons we feel measure X3629 has the potential to improve
patient outcomes by addressing causes of unplanned readmissions in patients
with cancer including those due to new and recurrent CDI. 1. Khan A, Raza S,
Batul SA, et al. The evolution of Clostridium difficile infection in cancer
patients: epidemiology, pathophysiology, and guidelines for prevention and
management. Recent patents on anti-infective drug discovery 2012;7:157-70.
2. Chopra T, Alangaden GJ, Chandrasekar P. Clostridium difficile infection in
cancer patients and hematopoietic stem cell transplant recipients. Expert
review of anti-infective therapy 2010;8:1113-9. 3. Raza S, Baig MA, Russell H,
Gourdet Y, Berger BJ. Clostridium difficile infection following chemotherapy.
Recent patents on anti-infective drug discovery 2010;5:1-9. 4. Cornely OA,
Miller MA, Fantin B, Mullane K, Kean Y, Gorbach S. Resolution of Clostridium
difficile-associated diarrhea in patients with cancer treated with fidaxomicin
or vancomycin. J Clin Oncol 2013;31:2493-9. 5. Campbell R, Dean B, Nathanson
B, Haidar T, Strauss M, Thomas S. Length of stay and hospital costs among
high-risk patients with hospital-origin Clostridium difficile-associated
diarrhea. Journal of medical economics 2013;16:440-8.(Submitted by: Merck,
Sharp and Dohme, Inc.)
- A potential barrier would be not having a concrete, working definition of
the phrase, ìpotentially avoidableî.(Submitted by: American Academy of
Pediatrics)
- [Pre-workgroup meeting comment] Position: The ADCC strongly
supports adoption of this measure as a more appropriate measure than the
30-Day All Cause Readmission measure (#1789) for our centers. Final testing
for this measure is nearing completion. However, the current testing for this
measure demonstrates that it excludes readmissions that are not attributable
to quality of care issues. Because our centers only care for cancer patients,
a more sensitive measure like this will help us to direct our efforts to
addressing truly preventable readmissions, thereby improving the quality of
care in our centers. Would addition of the measure add value to the program
measure set? Readmission following hospitalization is one of the facets of
cancer care that may be preventable, and should be addressed for the
opportunity to lower costs and improve patient outcomes. The Alliance of
Dedicated Cancer Centers (ADCC) emphasizes the importance of quality care for
patients through novel research and innovative approaches to treatment for
patients diagnosed with cancer. These centers recognize the value that can be
added to patientsí lives by reducing unnecessary readmissions, their length of
stay, and helping them to spend more nights at home in their beds. What is
the measureís potential to improve patient outcomes? The goal of 30-Day
Unplanned Readmissions for Cancer Patients is to identify causes of
unnecessary or preventable readmissions for cancer patients and take action to
reduce these numbers for facilities. Would use of the measure create undue
data collection or reporting burden? No, this measure is written to be
captured through administrative claims data. Is there a better measure
available or does a measure already in the program set address a particular
program objective? The HWR measure specifically excludes PPS-Exempt Cancer
Centers and cancer patients from calculation, presumably because the
developers recognized the complexity of accuracy of measuring readmissions in
the cancer population. Therefore, this is the only measure that is structured
for application to the PCHQR program. (Submitted by: Alliance of Dedicated
Cancer Centers)
| (Program: Inpatient Quality Reporting
Program ; MUC ID: X3689) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- We support this measure and the MAPís recommendation, but note that a
stronger measure would include some sort of validation mechanism to ensure the
survey is completed.(Submitted by: Society of Hospital Medicine)
- [Pre-workgroup meeting comment] Determine methodology as staff log
on often deters participation and skews results. Look at percentage of
participation and if incentives were needed increase participation. Determine
why staff are not participating. This appears to be the only measure that
assesses leadership in any way. How can can you assess a ship without
assessing the captain? The greatest problem from staff point of view is
managers and leaders. Melnyck study says chief barrier to evidenced based
practice yet you have no other accountability measures that may reduce costs
and complications by 30 per cent?(Submitted by: self)
| (Program: Ambulatory Surgical Centers Quality Reporting
Program ; MUC ID: X3697) |
- [Pre-workgroup meeting comment] The ASC Quality Collaboration is
supportive of the idea of a patient experience of care survey appropriate to
the outpatient surgical setting. We have been involved with the CMS project
to develop an Outpatient and Ambulatory Surgery Experience of Care Survey. We
have served on the Technical Expert Panel and assisted with the recruitment of
the 18 ASCs that piloted the instrument. The survey instrument has yet to be
finalized and made public. This measure appears to have been derived from the
draft survey, and therefore we believe its inclusion on the MUC List is
premature. The instrument and testing to support its construction and use are
not available for evaluation, making it is hard to understand how the MAP
could arrive at an informed decision regarding this measure at this point in
time. We have significant concerns regarding the costs of implementing and
using this survey, but we have been repeatedly assured by CMS throughout this
project that this instrument was being developed for voluntary use. To all
appearances, CMS is now attempting to force the use of the instrument by
including measures that are derived from it on the MUC List for adoption under
the ASC Quality Reporting Program. This is not something we can support
without having had the opportunity to assess the burden of use outside the
development and testing environment, where all costs have been absorbed by
CMS. We would welcome consideration of this measure at some point in the
future, after the survey itself, supporting data, and testing results have
been made available to the public and the experience of ASCs who have used the
survey voluntarily can be assessed for burden and other issues.(Submitted by:
ASC Quality Collaboration)
| (Program: Hospital Outpatient Quality Reporting Program;
MUC ID: X3697) |
- This is already part of many patient satisfaction tools; it would make
sense to add this as a measure for federal programs. (Submitted by: American
Academy of Pediatrics)
- Support the measure as-is. Further development may not be needed.
(Submitted by: Johns Hopkins Hospital)
| (Program: Ambulatory Surgical Centers Quality Reporting
Program ; MUC ID: X3698) |
- This is already part of many patient satisfaction tools. Up to this point,
the information provided has only been moderately helpful.(Submitted by:
American Academy of Pediatrics)
- [Pre-workgroup meeting comment] The ASC Quality Collaboration is
supportive of the idea of a patient experience of care survey appropriate to
the outpatient surgical setting. We have been involved with the CMS project
to develop an Outpatient and Ambulatory Surgery Experience of Care Survey. We
have served on the Technical Expert Panel and assisted with the recruitment of
the 18 ASCs that piloted the instrument. The survey instrument has yet to be
finalized and made public. This measure appears to have been derived from the
draft survey, and therefore we believe its inclusion on the MUC List is
premature. The instrument and testing to support its construction and use are
not available for evaluation, making it is hard to understand how the MAP
could arrive at an informed decision regarding this measure at this point in
time. We have significant concerns regarding the costs of implementing and
using this survey, but we have been repeatedly assured by CMS throughout this
project that this instrument was being developed for voluntary use. To all
appearances, CMS is now attempting to force the use of the instrument by
including measures that are derived from it on the MUC List for adoption under
the ASC Quality Reporting Program. This is not something we can support
without having had the opportunity to assess the burden of use outside the
development and testing environment, where all costs have been absorbed by
CMS. We would welcome consideration of this measure at some point in the
future, after the survey itself, supporting data, and testing results have
been made available to the public and the experience of ASCs who have used the
survey voluntarily can be assessed for burden and other issues.(Submitted by:
ASC Quality Collaboration (ASC QC))
| (Program: Hospital Outpatient Quality Reporting Program;
MUC ID: X3698) |
- Support the measure as-is. Further development may not be needed.
(Submitted by: Johns Hopkins Hospital)
| (Program: Ambulatory Surgical Centers Quality Reporting Program ;
MUC ID: X3699) |
- Measuring communication with these questions could potentially add value
from a patient perspective. A potential burden /challenge would be in
determining how and when to collect patient responses. (Submitted by: American
Academy of Pediatrics)
- [Pre-workgroup meeting comment] The ASC Quality Collaboration is
supportive of the idea of a patient experience of care survey appropriate to
the outpatient surgical setting. We have been involved with the CMS project
to develop an Outpatient and Ambulatory Surgery Experience of Care Survey. We
have served on the Technical Expert Panel and assisted with the recruitment of
the 18 ASCs that piloted the instrument. The survey instrument has yet to be
finalized and made public. This measure appears to have been derived from the
draft survey, and therefore we believe its inclusion on the MUC List is
premature. The instrument and testing to support its construction and use are
not available for evaluation, making it is hard to understand how the MAP
could arrive at an informed decision regarding this measure at this point in
time. We have significant concerns regarding the costs of implementing and
using this survey, but we have been repeatedly assured by CMS throughout this
project that this instrument was being developed for voluntary use. To all
appearances, CMS is now attempting to force the use of the instrument by
including measures that are derived from it on the MUC List for adoption under
the ASC Quality Reporting Program. This is not something we can support
without having had the opportunity to assess the burden of use outside the
development and testing environment, where all costs have been absorbed by
CMS. We would welcome consideration of this measure at some point in the
future, after the survey itself, supporting data, and testing results have
been made available to the public and the experience of ASCs who have used the
survey voluntarily can be assessed for burden and other issues.(Submitted by:
ASC Quality Collaboration (ASC QC))
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
X3699) |
- Support the measure as-is. Further development may not be
needed.(Submitted by: Johns Hopkins Hospital)
| (Program: Inpatient Quality
Reporting Program ; MUC ID: X3701) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- I believe that this new measure seeks to advance the utilization of
electronic records, and moves to reduce the reporting burden on hospitals. The
addition of clinical data will outweigh the need to adjust for SDS and, and
therefore should not wait for SDS adjustment. (Submitted by:
Public)
- Edwards supports the MAP recommendation for continued development of this
outcome measure for eventual use in the Hospital Inpatient Quality Reporting
program and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. Edwards
believes that readmission rates are an important indicator of quality of care
received during the admission and care coordination post-discharge. Edwards
supports efforts to incentivize the reporting of additional electronic
measures to reduce the burden associated with chart abstracted
measures.(Submitted by: Edwards Lifeciences)
- While the MAP voted to support continued development of this measure
before inclusion in the IQR and EHR Meaningful Use program, GNYHA believes
that significant development and testing is needed for this measure before it
can be considered valid and ready for public use. We do not support adoption
of this measure at this time. New York State has recent experience using
hybrid (both administrative and claims) data to risk adjust for sepsis
mortality. We have observed firsthand that hybrid data, and the integrity of
claims data in particular, is variable at best, and overall misleading. For
example, we have observed that hospitals inadvertently both under and over
report into administrative databases (mostly unknowingly and for varying
reasons). GNYHA supports a deeper understanding of this data through
development and testing prior to basing risk adjustment on this inconsistent
and unreliable data. (Submitted by: Greater New York Hospital
Association)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Medicare and
Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals
(CAHs) ; MUC ID: X3701) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- While the MAP voted to support continued development of this measure
before inclusion in the IQR and EHR Meaningful Use program, GNYHA believes
that significant development and testing is needed for this measure before it
can be considered valid and ready for public use. We do not support adoption
of this measure at this time. New York State has recent experience using
hybrid (both administrative and claims) data to risk adjust for sepsis
mortality. We have observed firsthand that hybrid data, and the integrity of
claims data in particular, is variable at best, and overall misleading. For
example, we have observed that hospitals inadvertently both under and over
report into administrative databases (mostly unknowingly and for varying
reasons). GNYHA supports a deeper understanding of this data through
development and testing prior to basing risk adjustment on this inconsistent
and unreliable data. (Submitted by: Greater New York Hospital
Association)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Ambulatory Surgical Centers Quality Reporting
Program ; MUC ID: X3702) |
- [Pre-workgroup meeting comment] The ASC Quality Collaboration is
supportive of the idea of a patient experience of care survey appropriate to
the outpatient surgical setting. We have been involved with the CMS project
to develop an Outpatient and Ambulatory Surgery Experience of Care Survey. We
have served on the Technical Expert Panel and assisted with the recruitment of
the 18 ASCs that piloted the instrument. The survey instrument has yet to be
finalized and made public. This measure appears to have been derived from the
draft survey, and therefore we believe its inclusion on the MUC List is
premature. The instrument and testing to support its construction and use are
not available for evaluation, making it is hard to understand how the MAP
could arrive at an informed decision regarding this measure at this point in
time. We have significant concerns regarding the costs of implementing and
using this survey, but we have been repeatedly assured by CMS throughout this
project that this instrument was being developed for voluntary use. To all
appearances, CMS is now attempting to force the use of the instrument by
including measures that are derived from it on the MUC List for adoption under
the ASC Quality Reporting Program. This is not something we can support
without having had the opportunity to assess the burden of use outside the
development and testing environment, where all costs have been absorbed by
CMS. We would welcome consideration of this measure at some point in the
future, after the survey itself, supporting data, and testing results have
been made available to the public and the experience of ASCs who have used the
survey voluntarily can be assessed for burden and other issues.(Submitted by:
ASC Quality Collaboration (ASC QC))
| (Program: Hospital Outpatient Quality Reporting Program;
MUC ID: X3702) |
- Support the measure as-is. Further development may not be
needed.(Submitted by: Johns Hopkins Hospital)
| (Program: Ambulatory Surgical Centers Quality Reporting Program ;
MUC ID: X3703) |
- [Pre-workgroup meeting comment] The ASC Quality Collaboration is
supportive of the idea of a patient experience of care survey appropriate to
the outpatient surgical setting. We have been involved with the CMS project
to develop an Outpatient and Ambulatory Surgery Experience of Care Survey. We
have served on the Technical Expert Panel and assisted with the recruitment of
the 18 ASCs that piloted the instrument. The survey instrument has yet to be
finalized and made public. This measure appears to have been derived from the
draft survey, and therefore we believe its inclusion on the MUC List is
premature. The instrument and testing to support its construction and use are
not available for evaluation, making it is hard to understand how the MAP
could arrive at an informed decision regarding this measure at this point in
time. We have significant concerns regarding the costs of implementing and
using this survey, but we have been repeatedly assured by CMS throughout this
project that this instrument was being developed for voluntary use. To all
appearances, CMS is now attempting to force the use of the instrument by
including measures that are derived from it on the MUC List for adoption under
the ASC Quality Reporting Program. This is not something we can support
without having had the opportunity to assess the burden of use outside the
development and testing environment, where all costs have been absorbed by
CMS. We would welcome consideration of this measure at some point in the
future, after the survey itself, supporting data, and testing results have
been made available to the public and the experience of ASCs who have used the
survey voluntarily can be assessed for burden and other issues.(Submitted by:
ASC Quality Collaboration (ASC QC))
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
X3703) |
- Support the measure as-is. Further development may not be
needed.(Submitted by: Johns Hopkins Hospital)
| (Program: Home Health
Quality Reporting Program; MUC ID: X3704) |
- AdvaMed supports the MAP recommendation for conditional support pending
further development and NQF endorsement.(Submitted by: AdvaMed)
- AGS believes that this is an important measure, as long as there is a
provision for those ulcers that are deemed ìnot preventableî and not on
hospice as well as hospice patients. (Submitted by: American Geriatrics
Society)
- We would like to know how the following scenario would be viewed: A
patient is admittied to home care with an unstageable pressure ulcer at
SOC/ROC. During the course of home care the unstageable pressure ulcer is
cleaned up and is evaluated as a stage III or IV. Upon discharge, the pressure
ulcer is assessed as a "totally epithelialized" stage III or IV. WOCN
guidelines would consider this pressure ulcer improved, yet we can't call it
"healed". Since the unstageable pressure ulcer is now considered a stage III
or IV, would it be considered worsened, stablized or improved in calculation?
We believe it should be considered 'improved' as this is consistent with WOCN
guidelines. The home care agency should therefore be given credit for the
effort involved in promoting that wound's healing by achieveing
epithelialization (a positive accomplishment).(Submitted by: Johns Hopkins
Hospital)
- TAHCH supports the exclusion of patients discharged to hospice for this
measure. (Submitted by: Texas Association for Home Care & Hospice
)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- WOCN supports measures to capture adverse events across settings. In
addition important changes such as the availability of certified wound care
nurses to perform assessments and skin care resource teams should be
considered as structral measures in future measures.(Submitted by: Wound
Ostomy and Continence Nurses)
- VNAA supports the importance of preventing new wounds and the
deterioration of wounds while in home health but has concerns about this
measure for several reasons. We do think that the comments from MAP members
are important to include in this measure. The VNAA concerns are the
following: In home health, caring for patients with pressures ulcers is
different than institutional settings. First patients are not seen 24 hours a
day as they are in other post-acute institutional settings but usually several
times a week depending on the level of care needed. Important factors in
preventing the decline in or presence of a wound would be the availability of
a willing and able caregiver. Partnership with caregivers is a critical aspect
to care of the patient in the home but this is most important with patients
who are bedbound or patients with limited mobility who have pressure ulcers.
These partnerships are a key factor in the ability to care for these patients
in a home care setting. Preventing decline is most successful when patients
receive optimum nutrition. This factor cannot be as easily controlled in home
care settings as it is in SNF, ITCH and IRB settings. Additionally, referring
physicians do not always identify the underlying etiology of the wound
resulting in treatment that not is appropriate. Also staging of the wound may
not be correct at admission so patients may have wounds that are at a higher
stage at discharge, not because they worsen but because they were not
correctly identified at the appropriate stage at admission. Referring
physicians are not always knowledgeable about the correct diagnosis and
staging of chronic wounds. For wound care adequate risk-adjustment is
important. Factors that takes into account the availability and willingness
of a caregiver, patientís current mobility and socio-economic status are
critical to be included in a risk-adjustment model. These factors affect the
ability for home health to prevent decline or presence of a new wound. VNAA
supports the importance of preventing new wounds and the deterioration of
wounds while in home health but has concerns about this measure for several
reasons. We do think that the comments from MAP members are important to
include in this measure. The VNAA concerns are the following: In home health,
caring for patients with pressures ulcers is different than institutional
settings. First patients are not seen 24 hours a day as they are in other
post-acute institutional settings but usually several times a week depending
on the level of care needed. Important factors in preventing the decline in or
presence of a wound would be the availability of a willing and able caregiver.
Partnership with caregivers is a critical aspect to care of the patient in the
home but this is most important with patients who are bedbound or patients
with limited mobility who have pressure ulcers. These partnerships are a key
factor in the ability to care for these patients in a home care setting.
Preventing decline is most successful when patients receive optimum nutrition.
This factor cannot be as easily controlled in home care settings as it is in
SNF, ITCH and IRB settings. Additionally, referring physicians do not always
identify the underlying etiology of the wound resulting in treatment that not
is appropriate. Also staging of the wound may not be correct at admission so
patients may have wounds that are at a higher stage at discharge, not because
they worsen but because they were not correctly identified at the appropriate
stage at admission. Referring physicians are not always knowledgeable about
the correct diagnosis and staging of chronic wounds. For wound care adequate
risk-adjustment is important. Factors that takes into account the
availability and willingness of a caregiver, patientís current mobility and
socio-economic status are critical to be included in a risk-adjustment model.
These factors affect the ability for home health to prevent decline or
presence of a new wound. (Submitted by: VNAA)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Currently available remote patient monitoring technologies are equipped with
sensors that detect patient position and movement and notify caregivers of the
need to reposition the patient in order to reduce pressure, which may
contribute to the development of pressure ulcers.(Submitted by:
AdvaMed)
| (Program: Long-Term
Care Hospitals Quality Reporting Program; MUC ID: X3705) |
- AdvaMed supports the MAP recommendation for encouraged continued
development of this measure. The measure addresses an important patient safety
priority for LTCHs.(Submitted by: AdvaMed)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Currently available modes of invasive mechanical ventilation encourage
patient spontaneous breathing and promote liberation from mechanical
ventilation, contributing to successful spontaneous breathing
trials.(Submitted by: AdvaMed)
| (Program: Long-Term Care Hospitals Quality
Reporting Program; MUC ID: X3706) |
- AdvaMed supports the MAP recommendation for encouraged continued
development of this measure. The measure addresses an important patient safety
priority for LTCHs. Successful weaning is associated with decreased
morbidity, mortality, and resource use.(Submitted by: AdvaMed)
- As CMS moves forward with the implementation of the IMPACT Act, AOTA
believes it is critical to require only one assessment instrument for quality
and payment for each post- acute care (PAC) setting in order to prevent
confusion and reduce administrative burden. We encourage measure
specifications to be further developed with risk adjustment for socioeconomic
status. For measures receiving ìconditional support,î AOTA agrees that the
measure revisions enumerated by the MAP must be made, but we recommend that
NQF require those revisions be made by the measure stewards within a
well-defined and specified timeframe to ensure consistency with the needs of
the PAC setting to which the measure will apply.(Submitted by: The American
Occupational Therapy Association)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Currently available modes of invasive mechanical ventilation encourage
patient spontaneous breathing and promote liberation from mechanical
ventilation, contributing to successful weaning.(Submitted by:
AdvaMed)
- [Pre-workgroup meeting comment] The FAH has mixed views on this
measure. Measuring the rate of weans in a health care facility is good
conceptually. However, this particular measure is not very useful for
differentialing among hospitals because it is not risk adjusted. However, the
defintion of "weaning" is fairly strong because it does not exclude "partial
weans." We are concerned that is is a self reported measure for which the
reporting tool has not been defined.(Submitted by: Federation of American
Hospitals)
- [Pre-workgroup meeting comment] The concept of developing a process
measure around ventilator weaning is good. However, until there are
specifications for such a measure and a mechanism for collecting the
information, we cannot support the recommendation of this measure for the Long
Term Acute Care hospitals setting.(Submitted by: Federation of American
Hospitals)
| (Program: End-Stage Renal Disease Quality
Incentive Program ; MUC ID: X3716) |
- ASN does not support Measure E1919 and therefore does not support Measure
X3716. ASN believes that Measure E1919 is not adequately validated in
dialysis facilities, which in general are far smaller than the institutions in
which the majority of testing occurred. While we agree that many of the
preferred practices listed are useful for running medium and large-sized
organizations, they are not appropriate for a facility level quality metric,
where a small business model on the very local level is often followed.
Critically, in the limited period of time provided for reviewing these
proposed measures, we were unable to locate details of documentation of
testing of this measure in dialysis facilities, although as best can be
discerned from the measure specification, it was field tested at only 7
dialysis facilities in Texas only. Accordingly, we concur with the PAC/LTC
Workgroup that voted 56% to 44% against support. As stated in our prior
comments, ASN notes that this type of measure is designed to improve patient
experience; therefore, there is considerable overlap between the ëPreferred
Practicesí in NQF 1919 and the items surveyed in the ICH CAHPS. Additionally,
many of the ëPreferred Practicesí do not readily apply to the facility level,
with these best implemented by organizations with fairly large staffs. For
example, ëPreferred Practice 4í states: ìEstablish an internal mechanism for
developing strategies that involve using a committee of current diverse staff
for recruitment, retention, and promotion of staff that reflect the community
at all levels of the organization (including upper management).î This, as
written, clearly does not apply to a facility where there may be between 10
and 20 employees. Additional several of these elements are duplicative with
the ESRD Conditions for Coverage (see tags V451, V451, V452, V453), while
others (for example Preferred Practice 30) refer to following existing local,
state and federal laws and regulations, a statement that should not require a
QIP metric. Preferred Practice 32, on community outreach, states in the
specifications that: ìOrganizations should collaborate with community
organizations, in particular for health education programs, where they can
help to raise awareness about local healthcare services.î This implies a role
for prevention in the community, which, although important, is currently not a
goal of dialysis facilities and will not impact current patients. While NQF
1919 is well-intentioned, most of the 12 preferred practices are beyond the
scope of individual dialysis facilities, which should, per their mission, be
focused on delivering dialysis care. In sum, 1) this measure does not readily
apply to many individual dialysis facilities, 2) elements which are applicable
are generally already addressed within existing laws and the Conditions for
Coverage, 3) elements within this measure that are applicable will be captured
in ICH CAHPS which assesses patient impressions of whether competent care is
occurring, and 4) this measure could substantially increase documentation
demands and facility burdens with no evidence of a beneficial effect on
dialysis patient outcomes. (Submitted by: American Society of Nephrology
(ASN))
- We are not supportive of measure as our review of the supporting
documentation does not show sufficient testing in ESRD facilities. More
testing needs to be done to determine feasibility in an ESRD
setting.(Submitted by: DaVita HealthCare Partners)
- KCP acknowledges that cultural competency is an important health care
priority and that the cultural competency MUCs would serve to expand the ESRD
measure set to include nonclinical aspects of care such as patient engagement.
However, KCP believes that as these measures have neither been adequately
tested in the dialysis facility setting nor demonstrated as having any impact
on patient care or outcomes, they are not appropriate for use in the QIP,
which should be limited to care delivery in the dialysis facility setting. As
with the medications reconciliation MUCs, the PAC/LTC Workgroup voted 56% to
44% against support (E1919) and conditional support pending NQF endorsement
(X3716). KCP concurs and opposes both E1919 and X3716, and urges the MAP
Coordinating Committee to do likewise. KCP notes that while E1919 is
NQF-endorsed and is in use for internal and external QI purposes, it has not
been used for public reporting or payment. Moreover, while E1919 was
specified for use in and has been tested in dialysis facilities (among other
settings), testing was limited to seven dialysis facilities within a single
organization in Texas. Given the uniqueness of the setting and the complexity
of the patients receiving care therein, KCP does not believe that this level
of testing is sufficient to deem the measure appropriate for use in dialysis
facilities. KCP also stresses that, given the intrinsic burden associated
with health care surveys, whatever cultural competency measure is ultimately
adopted for use in the QIP should be empirically linked to at least some
improvement in care and/or outcomes stemming from the assessment. This has
not yet been demonstrated for this measure. We additionally note that there
is some overlap with the ICH-CAHPS domains. As research is currently abundant
in this area, we urge the MAP Coordinating Committee to wait for the
development of a more appropriate cultural competency tool, with no redundancy
with existing surveys and a demonstrative efficacy in the dialysis setting.
KCP reiterates that the issue of burden is complex and must be approached
with caution. Each survey required places a heavier load on physicians,
staff, and patients. We stress that it is critically important before
adopting the cultural competency measures that additional testing be performed
and that use of the measures in the dialysis facility setting be better
understood. We believe that as currently specified, E1919 and its reporting
measure X3716 would be burdensome and have not been demonstrated to yield
accurate data or to improve care, outcomes, or patient experience in the
dialysis facility setting. Accordingly, the measures should not be
supported/conditionally supported (respectively) by the MAP.(Submitted by:
Kidney Care Partners (KCP))
- 2. NKF believes that the dialysis care team should be properly trained on
how to communicate, prescribe and deliver healthcare in a manner that respects
individualsí beliefs, attitudes, and behaviors and that overcomes language
barriers. However, because the measures of cultural competency are based on
another survey tool that is in part redundant with the in-center hemodialysis
CAHPs survey, NKF opposes the cultural competency measures as designed:
ï E1919 Cultural Competency Implementation Measure ï X3716 Cultural
Competency Reporting Measure The tool used to evaluate cultural competency has
some overlap with the in-center hemodialysis CAHPs survey for which twice a
year administration is already a requirement in the ESRD QIP and will be used
to evaluate patient satisfaction with their care in 2018. Requiring
completion of an additional survey places a burden on patients and healthcare
practitioners. Until such a time that one survey tool can be designed that
incorporates both relevant patient satisfaction questions and cultural
competency questions we believe that a separate measure of cultural competency
would only place an undue burden on patients and counteract much of the
benefit.(Submitted by: National Kidney Foundation)
- [Pre-workgroup meeting comment] ASN does not support Measure E1919
and therefore does not support Measure X3716. ASN believes that Measure E1919
is not adequately validated in dialysis facilities, which in general are far
smaller than the institutions in which the majority of testing occurred. While
we agree that many of the preferred practices listed are useful for running
medium and large-sized organizations, they are not appropriate for a facility
level quality metric, where a small business model on the very local level is
often followed. Critically, in the limited period of time provided for
reviewing these proposed measures, we were unable to locate details of
documentation of testing of this measure in dialysis facilities, although as
best can be discerned from the measure specification, it was field tested at 7
dialysis facilities in Texas only. This type of measure is designed to improve
patient experience; therefore, there is considerable overlap between the
ëPreferred Practicesí in NQF 1919 and the items surveyed in the ICH CAHPS.
Additionally, many of the ëPreferred Practicesí do not readily apply to the
facility level, with these best implemented by organizations with fairly large
staffs. For example, ëPreferred Practice 4í states: ìEstablish an internal
mechanism for developing strategies that involve using a committee of current
diverse staff for recruitment, retention, and promotion of staff that reflect
the community at all levels of the organization (including upper management).î
This, as written, clearly does not apply to a facility where there may be 10
to 20 employees. Additional several of these elements are duplicative with the
ESRD Conditions for Coverage (see tags V451, V451, V452, V453), while others
(for example Preferred Practice 30) refer to following existing local, state
and federal laws and regulations, a statement that should not require a QIP
metric. Preferred Practice 32, on community outreach, states in the
specifications that: ìOrganizations should collaborate with community
organizations, in particular for health education programs, where they can
help to raise awareness about local healthcare services.î While NQF 1919 is
well-intentioned, most of the 12 preferred practices are beyond the scope of
individual dialysis facilities, which should, per their mission, be focused on
delivering dialysis care. In sum, 1) this measure does not readily apply to
many individual dialysis facilities, 2) elements which are applicable are
generally already addressed within existing laws and the Conditions for
Coverage, 3) elements within this measure that are applicable will be captured
in ICH CAHPS which assesses patient impressions of whether competent care is
occurring, and 4) this measure could substantially increase documentation
demands and facility burdens with no evidence of a beneficial effect on
dialysis patient outcomes.(Submitted by: American Society of
Nephrology)
| (Program: End-Stage Renal Disease
Quality Incentive Program ; MUC ID: X3717) |
- ASN applauds NQFís conditional support of this measure and supports its
inclusion in this yearís MAP.(Submitted by: American Society of Nephrology
(ASN))
- 1) Kt/V UREA as a sole measure of dialysis adequacy is misleading. It
represents clearance on only 1 of the ~18 dialysis session per month. 2) Kt/V
UREA should be specified. UREA is the solute that is used for Kt/V
measurements. UREA itself is non toxic. 3) WIth current dialysis technologies,
most patients can achieve a goal Kt/V UREA. 4) This measure does not account
for session duration or compliance as an assessment of adequacy. 5) LDOs
should not tie-in staff bonuses to meeting this requirement as it opens
possibility for manipulation of the way samples for Kt/V UREA are collected.
(Submitted by: Johns Hopkins Hospital)
- KCP supports the Post-Acute Care/Long-Term Care (PAC/LTC) Workgroupís
recommendation for conditional support for X3717, pending NQF endorsement and
also subject to the public availability of testing results. All three
adequacy measures (X3717, X3718, and X2051) are composites. Combining
measures into a composite format can materially alter the properties intrinsic
to the component measures; even though the individual measures have been
tested, this does not negate the need for the composite measures to be tested.
Additionally, based on the specifications CMS provided to MAP, we note
apparent variations between X3717 and its component NQF-endorsed measures and
believe the variations should be justified and tested: ï X3717 uses
patient-months; NQF 0249 and 1423 (the components of X3717) use a straight
patient count. ï X3717 and NQF 1423 exclude patients on dialysis for <90
days; NQF 0249 excludes patients on dialysis <6 months. ï X3717 and NQF
0249 only include patients dialyzing three times per week; NQF 1423 includes
patients dialyzing three or four times weekly.(Submitted by: Kidney Care
Partners (KCP))
- The updated KDOQI draft hemodialysis adequacy guidelines are currently
undergoing internal review by NKFís Scientific Advisory Board. Once that
review is complete, in early February, the draft guidelines will be available
for public review and comment (interested parties can register now to review
the guidelines at
https://www.kidney.org/professionals/KDOQI/guidelines_commentaries). Currently
these proposed adequacy measures are in line with those draft guidelines as
well as the 2006 KDOQI hemodialysis and peritoneal dialysis adequacy
guidelines currently in place. However, we point out that these are minimum
standards for achievements and higher targets may be appropriate, particularly
for patients who struggle with fluid management.(Submitted by: National Kidney
Foundation)
- [Pre-workgroup meeting comment] ASN applauds this measure and
supports its inclusion in this yearís MAP.(Submitted by: American Society of
Nephrology)
| (Program: End-Stage Renal
Disease Quality Incentive Program ; MUC ID: X3718) |
- ASN applauds NQFís conditional support of this measure and supports its
inclusion in this yearís MAP.(Submitted by: American Society of Nephrology
(ASN))
- 1) Kt/V UREA as a sole measure of dialysis adequacy is misleading. It
represents clearance on only 1 of the ~18 dialysis session per month. 2) Kt/V
UREA should be specified. UREA is the solute that is used for Kt/V
measurements. UREA itself is non toxic. 3) WIth current dialysis technologies,
most patients can achieve a goal Kt/V UREA. 4) This measure does not account
for session duration or compliance as an assessment of adequacy. 5) LDOs
should not tie-in staff bonuses to meeting this requirement as it opens
possibility for manipulation of the way samples for Kt/V UREA are collected.
(Submitted by: Johns Hopkins Hospital)
- KCP supports the PAC/LTC Workgroupís recommendation for conditional
support for X3718, pending NQF endorsement and also subject to the public
availability of testing results. All three adequacy measures (X3717, X3718,
and X2051) are composites. Combining measures into a composite format can
materially alter the properties intrinsic to the component measures; even
though the individual measures have been tested, this does not negate the need
for the composite measures to be tested. Additionally, based on the
specifications CMS provided to MAP, we note apparent variations between X3718
and its component measures and believe the variations should be justified and
tested: ï X3718 and its component measure Minimum Kt/V for Pediatric
Peritoneal Dialysis Patients (not endorsed) use patient-months; X3718ís second
component measure, NQF 0318 uses a straight patient count. (Submitted by:
Kidney Care Partners (KCP))
- This measure is in alignment with the 2006 KDOQI peritoneal dialysis
adequacy guidelines. However, we point out that these are minimum standards
for achievements and higher targets may be appropriate, particularly for
patients who struggle with fluid management.(Submitted by: National Kidney
Foundation)
- [Pre-workgroup meeting comment] ASN applauds this measure and
supports its inclusion in this yearís MAP.(Submitted by: American Society of
Nephrology)
| (Program: Ambulatory Surgical Centers Quality Reporting Program ;
MUC ID: X3719) |
- [Pre-workgroup meeting comment] This measure focuses on an
intermediate outcome that is recognized as an important factor in reducing the
risk of surgical complications, including surgical site infection. It differs
from existing temperature management measures in being an outcome measure
rather than a process/outcome measure. The data needed for this measure is
generated during the patientís episode of care, allowing concurrent data
collection. Our experience with the measure suggests it can be implemented
without undue burden. The ASC QC recently put this measure into use for both
performance improvement and public reporting purposes.(Submitted by: ASC
Quality Collaboration (ASC QC))
| (Program: Ambulatory Surgical Centers Quality Reporting
Program ; MUC ID: X3720) |
- The Academy is pleased that the NQF agrees that this measure is highly
impactful and meaningful to patients. The Academy strongly supports this
measure for purposes of the ASCQR program. Measuring this outcome has
significant potential to reduce the rate of unplanned vitrectomies, with the
ASC playing a key role in arranging mentoring relationships for performance
improvement. Because the data needed for this measure is generated during the
patientís episode of care and is readily available for reporting, there is
very little burden associated with the use of this measure. We would welcome
the addition of this measure to the ASC Quality Reporting Program in the
future and believe that it should supplant ASC-11, which is currently
reportable on a voluntary basis under the Program.(Submitted by: American
Academy of Ophthalmology)
- [Pre-workgroup meeting comment] Our organizations strongly support
MUC ID X3720, Unplanned Anterior Vitrectomy for purposes of the Ambulatory
Surgical Center Quality Reporting Program. This measure evaluates the number
of cataract surgery patients who have an unplanned anterior vitrectomy.
Measuring the rate of these events presents an important opportunity to
improve the quality of care for the millions of Medicare patients who undergo
cataract surgery in the ASC setting. We have observed that measuring this
outcome has significant potential to reduce the rate of unplanned
vitrectomies, with the ASC playing a key role in arranging mentoring
relationships for performance improvement. Because the data needed for this
measure is generated during the patientís episode of care and is readily
available for reporting, there is very little burden associated with the use
of this measure. We would welcome the addition of this measure to the ASC
Quality Reporting Program in the future and believe that it should supplant
ASC-11, which is currently reportable on a voluntary basis under the Program.
(Submitted by: American Academy of Ophthalmology, American Society of
Cataract and Refractive Surgery, Outpatient Ophthalmic Surgery Society,
Society for Excellence in Eyesore)
- [Pre-workgroup meeting comment] Measuring the rate of unplanned
anterior vitrectomy in cataract surgery is an opportunity to improve the
quality of care for the millions of Medicare patients who undergo cataract
surgery in the ASC setting. We have observed that measuring and benchmarking
this outcome has the potential to reduce the rate of unplanned vitrectomies,
with the ASC playing a key role in arranging mentoring relationships for
performance improvement. Because the data for the measure is generated during
the patientís episode of care, it is readily available, and there is very
little burden associated with the use of this measure. The ASC QC recently put
this measure into use for both quality improvement and public reporting
purposes.(Submitted by: ASC Quality Collaboration (ASC QC))
| (Program: End-Stage Renal Disease Quality Incentive
Program ; MUC ID: X3721) |
- AstraZeneca agrees with this measure as it would provide more complete
information in evaluating and improving patient care in the outpatient
setting.(Submitted by: AstraZeneca Pharmaceuticals)
- This quality metric requires electronic data integration at the level of
LDOs. Only then will there be a meaningful improvement in data available to
the providers or the facilities.(Submitted by: Johns Hopkins
Hospital)
- ASN recognizes the critical importance of accurate medication
reconciliation and supports this measure in concept, but agrees with the
PAC/LTC Workgroup, who voted 56% to 44% against conditional support, that
additional measure testing and development is needed prior to this measure
being advanced. The society believes that defining when documentation or
reconciliation should occur and then testing this timing strategy is essential
for application to dialysis facilities. ASN agrees that identifying
medications and medication changes at admission to the dialysis unit, and with
each care setting transition is critical. However, ASN also notes that
reconciliation is not necessary at each routine dialysis session, preferring
serial regular reconciliation at an appropriate interval that should be
specified and tested given the balance between resource allocation and
benefits present in dialysis facilities. ASN would be pleased to work with
measure stewards to develop and refine this measure, which addresses a
critical patient safety issue.(Submitted by: American Society of Nephrology
(ASN))
- We are not supportive of measure as our review of the supporting
documentation does not show sufficient testing in ESRD facilities. More
testing needs to be done to determine feasibility in an ESRD
setting.(Submitted by: DaVita HealthCare Partners)
- KCP recognizes that true medication reconciliation is an important and
high priority, but neither E0419 nor X3721 adequately address this aspect of
care. Both measures emerged from the PAC/LTC Workgroup with the designation
ìconsensus not reached;î the Workgroup voted 56% to 44% against conditional
support pending testing (E0419) and endorsement (X3721). KCP opposes both
E0419 and X3721 and urges the MAP Coordinating Committee to do likewise. We
believe the specifications are fundamentally flawed for the dialysis facility
setting and hence should be opposed. KCP opposes X3721. This
structural/reporting measure has reportedly been tested in dialysis facilities
(though that information has not been made available), but is based on E0419,
for which validity and reliability have not been established in that setting.
We must therefore question both the process of testing a reporting measure in
a setting for which its foundation measure was neither intended nor tested, as
well as the soundness of the resultant findings. Additionally, KCP believes
E0419 and X3721 are essentially ìcheckbox measuresî that are unlikely to
improve medication reconciliation. We also note that E0419, the foundation
measure for X3721, looks at the percentage of visits in which a review of the
medications occurs; we believe this is an inappropriate specification when
dialysis facilities are the care setting with, typically, three or more
treatments per week. Testing a measure would shed light on the feasibility
and validity/reliability of the current E0419 specifications as presented, but
has not been performed in dialysis facilities. Reliability and validity
demonstrated in other care settings should not be assumed to transfer. We
cannot overemphasize the importance of testing medications documentation and
reconciliation measures specifically at the dialysis facility level. Again,
we are acutely sensitive to the potential utility of a valid medication
reconciliation measure for patients with ESRD on dialysis, because they take
an average of 8 to 10 medications, prescribed by 4 to 6 different doctors.
Further, all non-prescription medications and medications prescribed by other
providers must be included in the review. We believe that, as currently
specified, E0419 is not feasible and would yield inaccurate data (as would
X3721) because it is based on faulty specifications. Accordingly, MAP should
not conditionally support either measure.(Submitted by: Kidney Care Partners
(KCP))
- 3. NKF recognizes that medication reconciliation addresses an important
gap in the care of dialysis patients. Drug interactions, dose adjustment for
dialysis and avoidance of certain medications are important elements of care.
However, we oppose the following measures for use in the ESRD QIP as they are
currently designed: ï X3721 Medications Documentation Reporting
ï E0419 Documentation of Current Medications in the Medical Record
Unfortunately, these measures do not address true medication reconciliation
and therefore will have limited effect on improving patient outcomes. The
measure does not specify who in the dialysis facility should obtain the
information or how it should be obtained. There is no requirement to
coordinate with outside providers or pharmacists and currently no systems in
place to ensure interoperability of electronic health records that could aid
in avoiding medication errors including harmful drug interactions. In
addition, this is a percentage of visits where a medication review occurs.
Given that in-center hemodialysis patients typically receive dialysis three
times per week and home dialysis patients may visit the dialysis facility once
a month or less we do not see how this measure can feasibly be implemented for
a dialysis facility as currently designed. NKF looks forward to working with
CMS and NQF on ways medication reconciliation can be improved for dialysis
patients. (Submitted by: National Kidney Foundation)
- [Pre-workgroup meeting comment] ASN support this measure in
concept. However, the society believes that defining when documentation or
reconciliation should occur and then testing this timing strategy is essential
for application to dialysis facilities. ASN agrees that identifying
medications and medication changes at admission to the dialysis unit, and with
each care setting transition is critical. However, ASN also notes that
reconciliation is not necessary at each routine dialysis session, preferring
serial regular reconciliation at an appropriate interval that should be
specified and tested given the balance between resource allocation and
benefits present in dialysis facilities.(Submitted by: American Society of
Nephrology)
| (Program: Inpatient Quality Reporting
Program ; MUC ID: X3722) |
- AdvaMed supports the MAP recommendation to conditionally support inclusion
of this outcome measure in the Hospital Inpatient Quality Reporting program,
pending NQF review to ensure the measure is scientifically sound for use for
national public reporting and accountability programs. AdvaMed agrees that
acute care utilization after discharge for a heart failure admission is costly
to the healthcare system and potentially indicative of poor quality of care.
Use of this measure can lead to improved care during the admission and
improved care coordination post-discharge.(Submitted by: Advamed)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- Edwards supports the MAP recommendation to conditionally support inclusion
of this outcome measure in the Hospital Inpatient Quality Reporting program,
pending NQF review to ensure the measure is scientifically sound for use for
national public reporting and accountability programs. Edwards agrees that
acute care utilization after discharge for a heart failure admission is costly
to the healthcare system and potentially indicative of poor quality of care.
Use of this measure can lead to improved care during the admission and
improved care coordination post-discharge. Furthermore, by counting all types
of returns to acute care (observation, ED, and readmissions), the success of
efforts to improve care coordination can be better understood with this
measure than by looking at readmissions counts alone.(Submitted by: Edwards
Lifeciences)
- Although Premier understands and supports the concept of understanding the
spectrum of care that occurs post discharge, we feel this measure, which
incorporates many potential episodes into a single number, will be extremely
difficult to interpret and unhelpful. This measure equates a readmission of 8
days to and episode including a 4 day readmission stay 3 observation visits
and 2 ED visits. The two episodes are not equivalent and represent completely
different approaches to patient-centered care. Premier feels it is important
for patients and families to see the entire picture and supports a measure
that reports each of these components explicitly so that patients may
understand the scope of the post-discharge episode. We see very little
gained, and much information lost by reporting an arbitrarily created sum of
these components. It is just as easy, and much more informative to report
these components explicitly.(Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] agree with the addition of the
following text -Although some hospital returns are unavoidable, they may also
result from poor quality of care or inadequate transitional care. When
appropriate care transition processes are in place (for example, patient is
discharged to a suitable location, communication occurs between clinicians,
medications are correctly reconciled, timely follow-up is arranged, patients
with sleep apnea obtain diagnosis and management), fewer patients return to an
acute care setting, either for an emergency department (ED) visit, observation
stay, or hospital readmission during the 30 days post-discharge. Support:The
goal of this measure is to improve patient outcomes by providing patients, and
providers (physicians, and hospitals) with information about hospital-level,
risk-standardized outcomes following hospitalization for heart failure. In the
recently released 2013 ACC/AHA Heart Failure Guidelines, it recommends that
the Treatment of Sleep Disorders: Recommendation be a Class IIa It states
that ìContinuous positive airway pressure can be beneficial to increase LVEF
and improve functional status in patients with HF and sleep apnea(393ñ394).
(Level of Evidence: B)î It goes on to state ì Sleep disorders are common in
patients with HF. A study of adults with chronic HF treated with
evidence-based therapies found that 61% had either central or obstructive
sleep apnea. Despite having less sleep time and sleep efficiency compared with
those without HF, patients with HF, including those with documented sleep
disorders, rarely report excessive daytime sleepiness. Thus, a high degree of
suspicion for sleep disorders should be maintained for these patients. The
decision to refer a patient to a sleep study should be based on clinical
judgment. The primary treatment for obstructive sleep apnea is nocturnal
continuous positive airway pressure. In a major trial, continuous positive
airway pressure for obstructive sleep apnea was effective in decreasing the
apneañhypopnea index, improving nocturnal oxygenation, increasing LVEF,
lowering norepinephrine levels, and increasing the distance walked in 6
minutes; these benefits were sustained for up to 2 years . Smaller studies
suggest that continuous positive airway pressure can improve cardiac function,
sympathetic activity, and HRQOL in patients with HF and obstructive sleep
apnea. Studies have shown the benefit of the use of CPAP as it can Increase
LVEF By 35% in HF patients with SDB (Kaneko et al. N Engl J Med 2003)
Performing diagnostic unattended sleep studies and initiating PAP treatment
in hospitalized cardiac patients (including HF patients) was feasible the
results indicate that hospital readmission and ED visits 30 days after
discharge were significantly lower in patients with cardiac disease and SDB
who adhered to PAP treatment. Severe, non-treated OSA increases the risk of
stroke and HF mortality and CPAP treatment reduced this excess of mortality in
OSA patients. (M.-A. MartÌnez-GarcÌa, et al, Am J Respir Crit Care Med
183;2011:A1058) (Submitted by: ResMed)
- [Pre-workgroup meeting comment] The ACEP Quality and Performance
Committee appreciates the opportunity to comment on the Hospital 30-day all
cause unplanned risk-standardized days in acute care following hospitalization
measures. Intensity and cost of ED visits and type 1 observation is much less
than for admission, in fact ED visits cost Medicare approximately one tenth of
an inpatient admission (Morganti 2013). These returns to acute outpatient care
should be weighted differently than readmissions given that emergency care may
be the only care available for those with acute illness or acute exacerbations
of chronic conditions for 128 out of 168 hours per week in many communities.
There has not been a chart review or validation of these metrics, which would
indicate that these returns to care were not urgent or emergent. In fact the
most recent data from the CDC NHAMCS indicate that 92% of all visits to the ED
are urgent or emergent across all payers, and that number is even higher for
the Medicare population (CDC 2014). Recent studies have categorized
observation care into four settings based on the use of a dedicated
observation unit and the use of observation protocols (Ross 2013). A type
1setting is a protocol driven observation unit, type 2- an observation unit
(without the use of protocols), type 3 - a bed anywhere in the hospital with
the use of protocols, and type 4-is discretionary care anywhere in a hospital.
Nine prospective randomized studies, the highest standard for clinical
research, have all shown better clinical and economic outcomes when care is
rendered in a type 1 setting (Ross 2012). A recent analysis of national claims
data compared observation care in a type 1 setting with traditional settings
using regional and national claims data. It found that type 1 settings offered
38% shorter stays, 44% lower admit rates, with estimated national cost savings
of $950 million per year for observation patients (Baugh 2012). In fact, the
ED is likely the most appropriate and beneficial setting of care for these
patients in addition to being the only setting of care outside regular
business hours. There is no compelling scientific evidence for this measure,
as DHHSís own research has demonstrated that national readmission rates, which
hovered around 19% between 2007 and 2011, had dropped to approximately 17.5%
by 2013, and that the decrease resulted from actual changes in care and not
greater use of observation units or emergency department care (DHHS 2014,
Cassel 2014). Baugh, C.W., A. K.Venkatesh, J. A. Hilton, P. A. Samuel, J. D.
Schuur, and J. S. Bohan. 2012. ìMaking Greater Use of Dedicated Hospital
Observation Units for Many Short-Stay Patients Could Save $3.1 Billion a
Year.î Health Affairs 31 (10): 2314ñ23. Christine K. Cassel, M.D., Patrick H.
Conway, M.D., Suzanne F. Delbanco, Ph.D., Ashish K. Jha, M.D., M.P.H., Robert
S. Saunders, Ph.D., and Thomas H. Lee, M.D. Getting More Performance from
Performance Measurement. N Engl J Med 2014; 371:2145-2147 Centers for Disease
Control and Prevention. National Hospital Ambulatory Medical Care Survey
Emergency Department 2011 Factsheet. Accessed on: November 18, 2014. Accessed
at:http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf Department
of Health and Human Services. New HHS data shows major strides made in patient
safety, leading to improved care and savings. May 7, 2014
(http://innovation.cms.gov/Files/reports/patient-safety-results.pdf) Morganti
KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, Vesely JV, Okeke EN,
Kellermann AL. The Evolving Role of Emergency Departments in the United
States. RAND Health 2013. Accessed on August 26, 2013. Accessed at:
http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf
Ross MA, Aurora T, Graff L, Suri P, OíMalley R, Ojo A, Bohan S, Clark C.
State of the Art: Emergency Department Observation Units. Critical Pathways in
Cardiology 2012;11: 128ñ138 Ross MA, Hockenberry JM, Mutter R, Wheatley M,
Pitts S. Protocol-Driven Emergency Department Observation Units Offer Savings,
Shorter Stays, And Reduced Admissions. Health Affairs. Pub pending, 2013 Dec;
32(12):2149-2156 (Submitted by: American College of Emergency Physicians
(ACEP) Quality & Performance Committee)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
| (Program: Medicare Shared Savings
Program; MUC ID: X3726) |
- Amgen supports MUC X3726 ìClinical Response to Oral Systemic or Biologic
Medicationsî for inclusion in the CMS quality programs for clinicians. Amgen
supports performance measures that encourage diagnosis and treatment of
psoriasis and psoriatic arthritis. Psoriasis is a systemic inflammatory
disease of the skin and is the most common autoimmune disease in US, affecting
nearly 7.5 million people (National Psoriasis Foundation). Up to thirty
percent of those with psoriasis can develop psoriatic arthritis, which causes
joint swelling and pain. With very few quality measures in the dermatologic
space, both measures address a significant measure gap. Both conditions can be
debilitating and can lead to permanent disability if left untreated, but
fortunately respond to various treatments, including systemic and biologic
immunotherapy. Identifying psoriatic arthritis in people with psoriasis can
lead to improved therapy. Evaluating clinical response to psoriasis
medications can determine the most effective treatment. This measure can also
enhance quality of life in the psoriasis population. We fully support this
measure that highlights the importance of evaluating treatment among psoriasis
patients. (Submitted by: Amgen)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3726) |
- We support the inclusion of this important outcome measure of psoriasis
care. We note that the support is conditional on satisfactory testing at the
clinician level and submission to NQF for consideration for endorsement. The
AAD has begun testing psoriasis measures (including X3274 and X3726) and
anticipates seeking NQF endorsement in 2016. This measure evaluates the
proportion of psoriasis patients receiving systemic or biologic therapy that
record physician- or patient-reported disease activity levels. Additionally,
this measure provides an opportunity to objectively assess the efficacy of
medications in a standardized fashion and how they affect symptoms and /or
improve social function compared to the associated risks. The addition of this
measure, along with measure X3274, would improve the care for psoriasis, the
most prevalent autoimmune disease in the U.S., affecting about 7.5 million
Americans. For dermatology care, PQRS has only a few measures, including only
one measure related to psoriasis and no outcomes measures. Adding this
dermatology-specific outcome measure to PQRS will help dermatologists continue
to report successfully, avoid penalties for under-reporting for programs such
as PQRS and the Value Based Payment Modifier, and more importantly, to
contribute to the quality and performance goals of CMS. (Submitted by:
American Academy of Dermatology)
- Amgen supports MUC X3726 ìClinical Response to Oral Systemic or Biologic
Medicationsî for inclusion in the CMS quality programs for clinicians. Amgen
supports performance measures that encourage diagnosis and treatment of
psoriasis and psoriatic arthritis. Psoriasis is a systemic inflammatory
disease of the skin and is the most common autoimmune disease in US, affecting
nearly 7.5 million people (National Psoriasis Foundation). Up to thirty
percent of those with psoriasis can develop psoriatic arthritis, which causes
joint swelling and pain. With very few quality measures in the dermatologic
space, both measures address a significant measure gap. Both conditions can be
debilitating and can lead to permanent disability if left untreated, but
fortunately respond to various treatments, including systemic and biologic
immunotherapy. Identifying psoriatic arthritis in people with psoriasis can
lead to improved therapy. Evaluating clinical response to psoriasis
medications can determine the most effective treatment. This measure can also
enhance quality of life in the psoriasis population. We fully support this
measure that highlights the importance of evaluating treatment among psoriasis
patients. (Submitted by: Amgen)
| (Program: Inpatient Quality Reporting
Program ; MUC ID: X3727) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- AGS comments that the relationship between this measure and the
readmission measure needs to be clarified to avoid confusion. (Submitted by:
American Geriatrics Society)
- Although Premier understands and supports the concept of understanding the
spectrum of care that occurs post discharge, we feel this measure, which
incorporates many potential episodes into a single number, will be extremely
difficult to interpret and unhelpful. This measure equates a readmission of 8
days to and episode including a 4 day readmission stay 3 observation visits
and 2 ED visits. The two episodes are not equivalent and represent completely
different approaches to patient-centered care. Premier feels it is important
for patients and families to see the entire picture and supports a measure
that reports each of these components explicitly so that patients may
understand the scope of the post-discharge episode. We see very little
gained, and much information lost by reporting an arbitrarily created sum of
these components. It is just as easy, and much more informative to report
these components explicitly.(Submitted by: Premier, Inc.)
- This may be problematic, as length of hospital stay will be determined by
comorbidities.(Submitted by: American Academy of Pediatrics)
- [Pre-workgroup meeting comment] The ACEP Quality and Performance
Committee appreciates the opportunity to comment on the Hospital 30-day all
cause unplanned risk-standardized days in acute care following hospitalization
measures. Intensity and cost of ED visits and type 1 observation is much less
than for admission, in fact ED visits cost Medicare approximately one tenth of
an inpatient admission (Morganti 2013). These returns to acute outpatient care
should be weighted differently than readmissions given that emergency care may
be the only care available for those with acute illness or acute exacerbations
of chronic conditions for 128 out of 168 hours per week in many communities.
There has not been a chart review or validation of these metrics, which would
indicate that these returns to care were not urgent or emergent. In fact the
most recent data from the CDC NHAMCS indicate that 92% of all visits to the ED
are urgent or emergent across all payers, and that number is even higher for
the Medicare population (CDC 2014). Recent studies have categorized
observation care into four settings based on the use of a dedicated
observation unit and the use of observation protocols (Ross 2013). A type
1setting is a protocol driven observation unit, type 2- an observation unit
(without the use of protocols), type 3 - a bed anywhere in the hospital with
the use of protocols, and type 4-is discretionary care anywhere in a hospital.
Nine prospective randomized studies, the highest standard for clinical
research, have all shown better clinical and economic outcomes when care is
rendered in a type 1 setting (Ross 2012). A recent analysis of national claims
data compared observation care in a type 1 setting with traditional settings
using regional and national claims data. It found that type 1 settings offered
38% shorter stays, 44% lower admit rates, with estimated national cost savings
of $950 million per year for observation patients (Baugh 2012). In fact, the
ED is likely the most appropriate and beneficial setting of care for these
patients in addition to being the only setting of care outside regular
business hours. There is no compelling scientific evidence for this measure,
as DHHSís own research has demonstrated that national readmission rates, which
hovered around 19% between 2007 and 2011, had dropped to approximately 17.5%
by 2013, and that the decrease resulted from actual changes in care and not
greater use of observation units or emergency department care (DHHS 2014,
Cassel 2014). Baugh, C.W., A. K.Venkatesh, J. A. Hilton, P. A. Samuel, J. D.
Schuur, and J. S. Bohan. 2012. ìMaking Greater Use of Dedicated Hospital
Observation Units for Many Short-Stay Patients Could Save $3.1 Billion a
Year.î Health Affairs 31 (10): 2314ñ23. Christine K. Cassel, M.D., Patrick H.
Conway, M.D., Suzanne F. Delbanco, Ph.D., Ashish K. Jha, M.D., M.P.H., Robert
S. Saunders, Ph.D., and Thomas H. Lee, M.D. Getting More Performance from
Performance Measurement. N Engl J Med 2014; 371:2145-2147 Centers for Disease
Control and Prevention. National Hospital Ambulatory Medical Care Survey
Emergency Department 2011 Factsheet. Accessed on: November 18, 2014. Accessed
at:http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf Department
of Health and Human Services. New HHS data shows major strides made in patient
safety, leading to improved care and savings. May 7, 2014
(http://innovation.cms.gov/Files/reports/patient-safety-results.pdf) Morganti
KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, Vesely JV, Okeke EN,
Kellermann AL. The Evolving Role of Emergency Departments in the United
States. RAND Health 2013. Accessed on August 26, 2013. Accessed at:
http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf
Ross MA, Aurora T, Graff L, Suri P, OíMalley R, Ojo A, Bohan S, Clark C.
State of the Art: Emergency Department Observation Units. Critical Pathways in
Cardiology 2012;11: 128ñ138 Ross MA, Hockenberry JM, Mutter R, Wheatley M,
Pitts S. Protocol-Driven Emergency Department Observation Units Offer Savings,
Shorter Stays, And Reduced Admissions. Health Affairs. Pub pending, 2013 Dec;
32(12):2149-2156 (Submitted by: American College of Emergency Physicians
Quality & Performance Committee)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
| (Program: Inpatient
Quality Reporting Program ; MUC ID: X3728) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by:
AdvaMed)
- AGS comments that the relationship between this measure and the
readmission measure needs to be clarified to avoid confusion. (Submitted by:
American Geriatrics Society)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Society of
Hospital Medicine)
- Although Premier understands and supports the concept of understanding the
spectrum of care that occurs post discharge, we feel this measure, which
incorporates many potential episodes into a single number, will be extremely
difficult to interpret and unhelpful. This measure equates a readmission of 8
days to and episode including a 4 day readmission stay 3 observation visits
and 2 ED visits. The two episodes are not equivalent and represent completely
different approaches to patient-centered care. Premier feels it is important
for patients and families to see the entire picture and supports a measure
that reports each of these components explicitly so that patients may
understand the scope of the post-discharge episode. We see very little
gained, and much information lost by reporting an arbitrarily created sum of
these components. It is just as easy, and much more informative to report
these components explicitly.(Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] The ACEP Quality and Performance
Committee appreciates the opportunity to comment on the Hospital 30-day all
cause unplanned risk-standardized days in acute care following hospitalization
measures. Intensity and cost of ED visits and type 1 observation is much less
than for admission, in fact ED visits cost Medicare approximately one tenth of
an inpatient admission (Morganti 2013). These returns to acute outpatient care
should be weighted differently than readmissions given that emergency care may
be the only care available for those with acute illness or acute exacerbations
of chronic conditions for 128 out of 168 hours per week in many communities.
There has not been a chart review or validation of these metrics, which would
indicate that these returns to care were not urgent or emergent. In fact the
most recent data from the CDC NHAMCS indicate that 92% of all visits to the ED
are urgent or emergent across all payers, and that number is even higher for
the Medicare population (CDC 2014). Recent studies have categorized
observation care into four settings based on the use of a dedicated
observation unit and the use of observation protocols (Ross 2013). A type
1setting is a protocol driven observation unit, type 2- an observation unit
(without the use of protocols), type 3 - a bed anywhere in the hospital with
the use of protocols, and type 4-is discretionary care anywhere in a hospital.
Nine prospective randomized studies, the highest standard for clinical
research, have all shown better clinical and economic outcomes when care is
rendered in a type 1 setting (Ross 2012). A recent analysis of national claims
data compared observation care in a type 1 setting with traditional settings
using regional and national claims data. It found that type 1 settings offered
38% shorter stays, 44% lower admit rates, with estimated national cost savings
of $950 million per year for observation patients (Baugh 2012). In fact, the
ED is likely the most appropriate and beneficial setting of care for these
patients in addition to being the only setting of care outside regular
business hours. There is no compelling scientific evidence for this measure,
as DHHSís own research has demonstrated that national readmission rates, which
hovered around 19% between 2007 and 2011, had dropped to approximately 17.5%
by 2013, and that the decrease resulted from actual changes in care and not
greater use of observation units or emergency department care (DHHS 2014,
Cassel 2014). Baugh, C.W., A. K.Venkatesh, J. A. Hilton, P. A. Samuel, J. D.
Schuur, and J. S. Bohan. 2012. ìMaking Greater Use of Dedicated Hospital
Observation Units for Many Short-Stay Patients Could Save $3.1 Billion a
Year.î Health Affairs 31 (10): 2314ñ23. Christine K. Cassel, M.D., Patrick H.
Conway, M.D., Suzanne F. Delbanco, Ph.D., Ashish K. Jha, M.D., M.P.H., Robert
S. Saunders, Ph.D., and Thomas H. Lee, M.D. Getting More Performance from
Performance Measurement. N Engl J Med 2014; 371:2145-2147 Centers for Disease
Control and Prevention. National Hospital Ambulatory Medical Care Survey
Emergency Department 2011 Factsheet. Accessed on: November 18, 2014. Accessed
at:http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf Department
of Health and Human Services. New HHS data shows major strides made in patient
safety, leading to improved care and savings. May 7, 2014
(http://innovation.cms.gov/Files/reports/patient-safety-results.pdf) Morganti
KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, Vesely JV, Okeke EN,
Kellermann AL. The Evolving Role of Emergency Departments in the United
States. RAND Health 2013. Accessed on August 26, 2013. Accessed at:
http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf
Ross MA, Aurora T, Graff L, Suri P, OíMalley R, Ojo A, Bohan S, Clark C.
State of the Art: Emergency Department Observation Units. Critical Pathways in
Cardiology 2012;11: 128ñ138 Ross MA, Hockenberry JM, Mutter R, Wheatley M,
Pitts S. Protocol-Driven Emergency Department Observation Units Offer Savings,
Shorter Stays, And Reduced Admissions. Health Affairs. Pub pending, 2013 Dec;
32(12):2149-2156 (Submitted by: American College of Emergency Physicians
(ACEP) Quality & Performance Committee)
- [Pre-workgroup meeting comment] Support pending NQF endorsement.
Complications, readmissions and mortality after medical conditions or patient
discharge may be reducible with application of currently available patient
monitoring technologies in the acute care and home care setting. These
patient monitoring technologies may permit ìearly warningî of complications
and permit intervention before complications worsen to increase inpatient
length of stay, cause unplanned readmission, or cause death.(Submitted by:
AdvaMed)
| (Program:
Medicare Shared Savings Program; MUC ID: X3729) |
- Amgen supports with modifications MUC X3729 ìStatin Therapy for the
Prevention and Treatment of Cardiovascular Diseaseî for inclusion in the CMS
quality programs for clinicians. Amgen supports comprehensive measures that
improve cholesterol management for the prevention and treatment of
cardiovascular disease. Current evidence from interventional and large
epidemiologic studies and human genetics provide strong evidence for the role
of LDL-C in CV risk. This evidence has supported the rationale and strong
clinical interest in pursuing clinical programs designed to further lower
LDL-C. With the removal of several lipid screening and lipid control measures
from both the Medicare Physician Quality Reporting System and the Medicare
Shared Savings Program, this measure does fill the current quality measure gap
in cholesterol management. Consistent with the new ACC/AHA guidelines for
cholesterol management, the measure addresses appropriate first-line
lipid-lowering therapy. Additionally, the measure recognizes the need to
address both LDL-C levels for identifying specific patient populations outside
of secondary prevention (i.e. LDL-C above 190) and LDL-C thresholds in the
diabetic population. We do recommend a few modifications to improve this
measure. We recommend that the measure description be broadened by replacing
the word ìstatinî in the title and ìstatin therapyî in the description with
ìcholesterol/lipid loweringî. Although statins are first-line therapy for
managing cholesterol, additional therapies are also effective in lowering
LDL-C and CV event rates, as demonstrated most recently from the results of
the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial
(IMPROVE IT). Although not a direct modification to this measure, we also
recommend the addition or development of a lipid screening measure consistent
with the specifications of this measure. Because the measure lists LDL-C
levels as a descriptor in the denominators, a quality measure addressing the
gap would improve its performance. These modifications are consistent with
the new guidelines as well as anticipate upcoming new therapies in cholesterol
lowering. (Submitted by: Amgen)
- Based on the 2013 ACC/AHA guidelines on the Treatment of Blood Cholesterol
to Reduce Atherosclerotic Cardiovascular Risk in Adults,† we recommend
additional language, "use of moderate to high intensity statin therapy, where
appropriate" be included for these patient groups.(Submitted by: AstraZeneca
Pharmaceuticals)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program:
Medicare and Medicaid EHR Incentive Programs for Eligible Professionals;
MUC ID: X3729) |
- Amgen supports with modifications MUC X3729 ìStatin Therapy for the
Prevention and Treatment of Cardiovascular Diseaseî for inclusion in the CMS
quality programs for clinicians. Amgen supports comprehensive measures that
improve cholesterol management for the prevention and treatment of
cardiovascular disease. Current evidence from interventional and large
epidemiologic studies and human genetics provide strong evidence for the role
of LDL-C in CV risk. This evidence has supported the rationale and strong
clinical interest in pursuing clinical programs designed to further lower
LDL-C. With the removal of several lipid screening and lipid control measures
from both the Medicare Physician Quality Reporting System and the Medicare
Shared Savings Program, this measure does fill the current quality measure gap
in cholesterol management. Consistent with the new ACC/AHA guidelines for
cholesterol management, the measure addresses appropriate first-line
lipid-lowering therapy. Additionally, the measure recognizes the need to
address both LDL-C levels for identifying specific patient populations outside
of secondary prevention (i.e. LDL-C above 190) and LDL-C thresholds in the
diabetic population. We do recommend a few modifications to improve this
measure. We recommend that the measure description be broadened by replacing
the word ìstatinî in the title and ìstatin therapyî in the description with
ìcholesterol/lipid loweringî. Although statins are first-line therapy for
managing cholesterol, additional therapies are also effective in lowering
LDL-C and CV event rates, as demonstrated most recently from the results of
the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial
(IMPROVE IT). Although not a direct modification to this measure, we also
recommend the addition or development of a lipid screening measure consistent
with the specifications of this measure. Because the measure lists LDL-C
levels as a descriptor in the denominators, a quality measure addressing the
gap would improve its performance. These modifications are consistent with
the new guidelines as well as anticipate upcoming new therapies in cholesterol
lowering. (Submitted by: Amgen)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- Based on the 2013 ACC/AHA guidelines on the Treatment of Blood Cholesterol
to Reduce Atherosclerotic Cardiovascular Risk in Adults,† we recommend
additional language, "use of moderate to high intensity statin therapy, where
appropriate" be included for these patient groups.(Submitted by: AstraZeneca
Pharmaceuticals)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] The addition of this measure would
add value as there is no other measure that captures all the patient groups
identified in the denominator. The measureís focus on the 3 guideline-based
high risk statin benefit groups, as well as the identification of specific LDL
levels for measurement within 2 of the benefit groups adds value by drawing
attention to the need to address LDL in these patients. However, we wish to
suggest amendments to this measure that could enhance its potential to improve
patient outcomes. First, we recommend the expansion of the numerator beyond
just statins to include other lipid-lowering agents. For many, the
combination of a statin with another drug (ezetimibe or niacin) is needed to
achieve the desired reduction. (Karalis 2012. doi:10.1155/2012/861924). This
is further supported by the positive results of the IMProved Reduction of
Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT). This trial
evaluated the potential benefit for reduction in major cardiovascular (CV)
events from the addition of ezetimibe versus placebo to statin therapy.
(Blazing, 2014: 205-212) IMPROVE-IT results were presented at the AHA
Scientific Sessions 2014, including separate analyses of the intent-to-treat
and on-treatment patient populations. Trial results met primary endpoint,
showing ~ 2% reduction in CV events with Vytorin (ezetimibe/simvastatin) vs.
simvastatin (HR=0.936, p=0.016; 6.4% relative risk reduction). IMPROVE-IT
results are consistent with the established relationship between absolute
reductions in LDL-C and reductions in major CV events. (Baigent, 2010: 167-81)
It is the first trial to show that adding a non-statin to a statin to further
reduce LDL-C levels can help to reduce CV events. Because of the need for
combination therapy to achieve therapeutic results and the time lag in
incorporating new evidence and drugs in the guidelines, the addition of
ìstatins and other lipid-lowering drugsî would allow the measure to be timely
as new evidence and drugs become available. Second, the AHA/ACC 2013
guidelines address 3 steps required to treat treatment LDL in order to achieve
favorable impact on CV outcomes: Step 1) recognition of risk and LDL
measurement, Step 2) initiate appropriate treatment based on the LDL level and
the patient subpopulation and Step 3) monitoring patient response and
intensifying treatment based on response (Figure 5, Stone, 2013: 3024-3025).
To achieve the goal treating cholesterol levels in order to reduce overall CV
risk and outcomes, there needs to be a ìfamilyî of measures that address all
the needed steps. The first step of diagnosing and initiating treatment is
addressed in this process measure but it is not sufficient to achieving the
desired clinical outcome for the patient. It does not address Step 2, whether
the patient was started on the appropriate intensity of statin treatment which
is a key element in the guideline. Those who prescribe a statin without
regard to the dosing and intensity recommendations will ëpassí the measure.
The intention of the guidelines is not to just start any statin at any dose,
as evidenced by the specificity of intensity of dosing by patient population
and the grouping of drugs with dosing into the different intensity
recommendations. The evidence does not support this approach as being
effective. Our concern is that this measure will give a passing mark to
everyone who orders a statin for a patient and will not have the intended
effect of providing patients with the intensity of therapy appropriate for
their level of risk. Another measure is needed that addresses whether the
patient received the appropriate intensity of treatment. Statin intolerance
has been reported to occur with frequencies of 10 -25% in clinical practice.
It is not clear how the measure as currently specified will address this
issue. Another measure is also needed which addresses monitoring and
intensification of treatment to achieve low-density lipoprotein cholesterol
(LDL-C) level reduction during the course of the measurement period, Step 3.
The recommendation to monitor lipid levels and adjust treatment comes with the
highest level of evidence and recommendation in the AHA/ACC guidelines (Grade
A, Strong Recommendation). The IMPROVE-IT results reemphasize the
importance of achieving LDL control. High LDL-C is a major risk factor for CV
events (Steinberg 2009:9546-7) which remains a leading cause of morbidity and
mortality across the world, accounting for an estimated 30 percent of all
global deaths. (Vogel, 2012: 2354-5) The evidence supports the importance of
this step in clinical practice. Despite treatment with lipid-lowering
therapy, many patients do not achieve optimal LDL-C control and may remain at
risk for CV events. (Waters 2009:28-34) This suboptimal response may be due
to many factors, including: efficacy limitations, intolerance to
lipid-lowering therapy, and treatment non-adherence, including failure to fill
the prescription. (Karalis, 2012: doi:10.1155/2012/861924) These factors are
recognized in the assessment of response and treatment decision-making, as
reflected in the treatment algorithm (Figure 5). One option is the creation
of another process measure that addresses measurement of the LDL levels and
dose adjustment. There have been measures like this in the past and they have
been removed from use. They assess the process of care and do not focus on
the real issue of major interest to the patient ñ the reduction of CV risk
through the reduction of their LDL to an acceptable level. For these reasons,
we believe another measure is needed which would assess the reduction or lack
of reduction in LDL-C levels and action taken, e.g. statin change or dose
adjustment and/or the need to add other lipid modifying therapies to statins.
An alternative is not to focus on process, the dosing of a drug initially
(Step 2) or on monitoring and intensification (Step 3), but to focus on an
intermediate outcome measure which addresses whether the patient achieved the
desired level of response, reduction of their LDL to an acceptable level,
which could be an absolute LDL level or to the lowest LDL level possible given
based on the individual patient. While there is concern with this approach,
the LDL level is what influences the patients CV risk. While we recognize
the rationale for not recommending use of absolute LDL levels, the current
reality is that patients are familiar with having an absolute LDL level as
their target. Patient engagement is a critical element in improving
healthcare. Measures need to be easily understood, actionable and provide the
transparency necessary for provider selection. LDL-C levels are an indicator
of a patientís CV risk. Lipid level reduction provides a clear goal to support
the continuum of care and to provide a marker for a patient regarding drug,
exercise and diet compliance. Lipid levels have been a key part of patientsí
education and awareness in the treatment of hyperlipidemia. It is a concept
well understood. Lipid levels have also been shown to be strong indicators of
outcomes in the IMPROVE-IT trial, and this factor is necessary to provide true
transparency of provider performance. Historically, there has been ëclinical
inertiaí in clinical practice when there were recommended LDL levels. It is
not clear that having a percent will be sufficient to guide physician care and
result in improved patient outcomes. The use of percentages, as recommended
for a treatment target in the guideline, does not work well as a measure
because of data collection issues. It also requires that the physician know
the previous levels if the statin was started by another physician. In
summary, we support this measure in general but are concerned that it is
possible to pass the measure by ordering a statin without regard to the
specific intensity recommendations associated with each patient population.
We also believe that additional intermediate outcome measures of LDL are
needed to ensure that the patientís CV risk will be reduced because the LDL
level has been reduced to an acceptable level. (Submitted by: SMT,
Inc.)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3729) |
- Amgen supports with modifications MUC X3729 ìStatin Therapy for the
Prevention and Treatment of Cardiovascular Diseaseî for inclusion in the CMS
quality programs for clinicians. Amgen supports comprehensive measures that
improve cholesterol management for the prevention and treatment of
cardiovascular disease. Current evidence from interventional and large
epidemiologic studies and human genetics provide strong evidence for the role
of LDL-C in CV risk. This evidence has supported the rationale and strong
clinical interest in pursuing clinical programs designed to further lower
LDL-C. With the removal of several lipid screening and lipid control measures
from both the Medicare Physician Quality Reporting System and the Medicare
Shared Savings Program, this measure does fill the current quality measure gap
in cholesterol management. Consistent with the new ACC/AHA guidelines for
cholesterol management, the measure addresses appropriate first-line
lipid-lowering therapy. Additionally, the measure recognizes the need to
address both LDL-C levels for identifying specific patient populations outside
of secondary prevention (i.e. LDL-C above 190) and LDL-C thresholds in the
diabetic population. We do recommend a few modifications to improve this
measure. We recommend that the measure description be broadened by replacing
the word ìstatinî in the title and ìstatin therapyî in the description with
ìcholesterol/lipid loweringî. Although statins are first-line therapy for
managing cholesterol, additional therapies are also effective in lowering
LDL-C and CV event rates, as demonstrated most recently from the results of
the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial
(IMPROVE IT). Although not a direct modification to this measure, we also
recommend the addition or development of a lipid screening measure consistent
with the specifications of this measure. Because the measure lists LDL-C
levels as a descriptor in the denominators, a quality measure addressing the
gap would improve its performance. These modifications are consistent with
the new guidelines as well as anticipate upcoming new therapies in cholesterol
lowering. (Submitted by: Amgen)
- Based on the 2013 ACC/AHA guidelines on the Treatment of Blood Cholesterol
to Reduce Atherosclerotic Cardiovascular Risk in Adults,† we recommend
additional language, "use of moderate to high intensity statin therapy, where
appropriate" be included for these patient groups.(Submitted by: AstraZeneca
Pharmaceuticals)
- The addition of this measure would add value as there is no other measure
that captures all the patient groups identified in the denominator. The
measureís focus on the 3 guideline-based high risk statin benefit groups, as
well as the identification of specific LDL levels for measurement within 2 of
the benefit groups adds value by drawing attention to the need to address LDL
in these patients. However, we wish to suggest amendments to this measure
that could enhance its potential to improve patient outcomes. First, we
recommend the expansion of the numerator beyond just statins to include other
lipid-lowering agents. It is understood that a process measure that
identifies a patient population of interest is only the beginning for a
screening quality improvement initiative. The data on the current LDL
measures supports the position that a quality measure alone is not sufficient
to improve the quality of care for patients. Experience with hospital measure
for statin therapy after hospitalization for acute myocardial infarction
provides valuable information about the impact of a similarly defined measure
on the actual care provided to patients. In their study, Arnold et al found
that almost all patients eligible for statins are prescribed them at the time
of discharge (87%). Only 1/3 were prescribed in doses recommended. At 12
month follow-up, Arnold et all reported that up-titration of medication only
occurred in 25% of patients; only 26% of patients were at goal dose of
statins. (Those with contraindications were not included in the analysis.)
Statin therapy was the least likely to be at goal doses compared with
beta-blockers and anti-glycemic therapy. (Arnold 2013:791-801) If this is the
only performance measure or intervention, it is not clear how or why this
measure the experience with this measure which is similar to the
hospital-based measure will be any different. Performance measures have been
most successful in achieving improvement in care when they are both publicly
reported AND linked to some consequence, e.g. linked to bonuses or value-based
payment. Rarely is a single measure enough to address the process of care
the will result in improvement in quality of care. The AHA/ACC 2013
guidelines identify 3 steps needed to achieve a favorable impact on a
patientís ASCVD risk and ultimately, their clinical outcome: 1) recognition
of risk and LDL measurement, 2) initiate appropriate treatment based on the
LDL level and the patient subpopulation and 3) monitor patient response and
intensify treatment based on a patientís response (Figure 5, Stone, 2013:
3024-3025). From the perspective of a performance measurement for quality
improvement, to achieve the goal of reducing a personís overall ASCVD risk and
clinicaloutcomes, there needs to be a ìfamilyî of measures that address all
the 3 steps. This measure addresses the first step of diagnosing and
initiating treatment but it is not sufficient to achieving the desired
clinical outcome for the patient. It does not address Step 2, whether the
patient was started on the appropriate intensity of statin treatment which is
a critical element in the guideline. There is significant confusion
associated with the guideline, with many taking the position that the LDL
level is no longer important because the guideline did not identify an LDL
target. Comments in published articles on the guidelines seems to assume that
tailored therapy, e.g. ordering an initial dose of the appropriate intensity,
will be sufficient with no further need for monitoring or intervention. They
miss the section and algorithm about monitoring for therapeutic response. The
guidelines does still believe the LDL level is important to clinical outcomes.
The ASCVD Risk Calculator includes the LDL level. In addition, there are
multiple statements about the importance of lowering the LDL: ï ìMoreover,
statin therapy reduces ASCVD events across the spectrum of baseline LDL-C
levels =70 mg/dL.î (S7) ï ìClassifying specific statins and doses by the
percent reduction in LDL-C level is based on evidence that the relative
reduction in ASCVD risk from statin therapy is related to the degree by which
LDL-C is lowered.î ï ìÖextensive evidence shows that each 39-mg/dL reduction
in LDL-C by statin therapy reduces ASCVD risk by about 20%.î (P S14) ï The
priority of the guideline is on prescribing high intensity doses of statins.
The information in the Full Report provides a better idea of how that
translates into clinical practice and LCL levels. It reports that in the
clinical studies ìhigh-intensity statin therapy resulted in mean LDLñC levels
of 53 to 79 mg/dL on treatment, with the large majority of participants in the
high-intensity statin group achieving an LDLñC <100 mg/dLî With this
measure as it is written, those who prescribe a statin without regard to the
dosing and intensity recommendations will ëpassí the measure without achieving
the goal of the guideline which is to get patients on the highest dose of
statins that is tolerated and to achieve the greatest amount of reduction in
LDL levels. It will not achieve the desired clinical outcome, reduction of
patient risk and patient events. Without additional information, this new
measure is more like a combination of a number of past Cholesterol Screening
measures (CAD, Stroke and PAD) which have not been shown to have a significant
impact on changing clinical practice and improving patient care. Statin
intolerance has been reported to occur with frequencies of 10 -25% in clinical
practice. It is not clear how the measure as currently specified will address
exceptions based on the individual patient characteristics. For many, the
combination of a statin with another drug (ezetimibe or niacin) is needed to
achieve the desired reduction. (Karalis 2012. doi:10.1155/2012/861924). This
is further supported by the positive results of the IMProved Reduction of
Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT). This trial
evaluated the potential benefit for reduction in major cardiovascular (CV)
events from the addition of ezetimibe versus placebo to statin therapy.
(Blazing, 2014: 205-212) IMPROVE-IT results were presented at the AHA
Scientific Sessions 2014, including separate analyses of the intent-to-treat
and on-treatment patient populations. Trial results met primary endpoint,
showing ~ 2% reduction in CV events with Vytorin (ezetimibe/simvastatin) vs.
simvastatin (HR=0.936, p=0.016; 6.4% relative risk reduction). IMPROVE-IT
results are consistent with the established relationship between absolute
reductions in LDL-C and reductions in major CV events. (Baigent, 2010: 167-81)
It is the first trial to show that adding a non-statin to a statin to further
reduce LDL-C levels can help to reduce CV events. A measure is needed that
addresses whether there has been an adequate response to treatment and/or
whether treatment with statins was adjusted or non-statins added and then
response monitored again. This approach is specifically stated in the
monitoring algorithm in the guidelines (Figure 5) and comes with the highest
level of evidence and recommendation in the AHA/ACC guidelines (Grade A,
Strong Recommendation). Because of the need for combination therapy in many
patients to achieve therapeutic results and the time lag in incorporating new
evidence and drugs in the guidelines, the addition of ìstatins and other
lipid-lowering drugsî would allow the measure to be timely as new evidence and
drugs become available. There has been significant push-back from physicians
about being measured/rewarded based on what they perceive is outside their
purview ñ patient adherence. Without getting into the discussion of the role
of the physician as educator and change agent, this position ignores the
clinical aspect of treatment which is addressed in the guidelines: the
significant variability in a patientís biological response to a drug. The
guideline addresses both the patient education/adherence issues as well as the
biological response and recommends monitoring for adherence and efficacy, with
the recommendation that inadequate response should be addressed with changes
in statin/dosing and consideration of the addition of non-statin drugs.
(Stone, 2013 Guideline, Figure 5) An alternative is not to focus on process,
the dosing of a drug initially (Step 2) or on monitoring and intensification
(Step 3), but to focus on an intermediate outcome measure which addresses
whether the patient achieved the desired level of response, a measure that
addresses the reduction of their LDL to an acceptable level, which could be an
absolute LDL level or to the lowest LDL level possible based on the individual
patient. While there is concern with this approach, the LDL level is what
influences the patients CV risk. The current reality is that patients are
familiar with having an absolute LDL level as their target. Patient
engagement is a critical element in improving healthcare. Measures need to be
easily understood, actionable and provide the transparency necessary for
provider selection. LDL-C levels are an indicator of a patientís CV risk
when used in the ASCVD Risk Calculator and an ìaid to monitoring response to
therapy and adherenceî and ëindicators of anticipate therapeutic response to
statin therapyî (Stone 2013.p21) Lipid level reduction provides a clear goal
to support the continuum of care and to provide a marker for a patient
regarding drug, exercise and diet compliance. Lipid levels have been a key
part of patientsí education and awareness in the treatment of hyperlipidemia.
It is a concept well understood. Lipid levels have also been shown to be
strong indicators of outcomes in the IMPROVE-IT trial, and this factor is
necessary to provide true transparency of provider performance. In summary, we
support this measure in principal but we do not see it as significantly
different in whether it will actually impact the quality of care anymore than
has occurred with the existing screening measures, including the hospital
measure for statin therapy after AMI. Screening measures are generally
ineffective by themselves and may cause harm because it is possible to pass
the measure by ordering a statin without regard to the specific intensity
recommendations associated with each patient population. To be effective,
performance measures are needed that addresses the real clinical issues:
prescribing appropriate doses of statins as initial therapy, monitoring for
therapeutic response and adjusting therapy/adding non-statins to achieve
desired response, as defined in Figure 5. We believe that additional
intermediate outcome measures of LDLl are needed to ensure that the patientís
CV risk will be reduced because the LDL has actually been reduced enough to be
meaningful to the patientís outcome. (Submitted by: SMT, Inc)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] ASN cannot support this measure as
written as data do not support initiating statins in prevalent dialysis
patients. This is stated in the recent KDIGO clinical practice guideline and
the US National Kidney Foundation KDOQI commentary on this guideline. ASN
supports this measure for non-dialysis CKD patients, but feels strongly that
viewing populations as homogenous in these measures is inappropriate,
particularly when well-conducted randomized clinical trials have shown
negative results.(Submitted by: American Society of Nephrology
(ASN))
| (Program: Medicare Shared Savings Program; MUC
ID: X3732) |
- TAHCH supports the referral to hospice for all patients who choose to
withdraw from dialysis or documentation why the referral was not made.
(Submitted by: Texas Association for Home Care & Hospice )
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3732) |
- 6. Withdrawing from dialysis is not an easy decision for patients and
their caregivers. However, when the decision is made, physicians should refer
patients for appropriate palliative care and patient and caregiver social
support provided as a component of hospice care. Therefore, NKF supports:
ï X3732 Adult Kidney Disease: Referral to Hospice NKF also notes that support
for this measure should not be interpreted to mean that referral to hospice
for patients treated with dialysis is only limited to instances when a patient
chooses to withdraw dialysis treatment. In some circumstances, patients with
terminal comorbidities may benefit from hospice care, but also wish to
continue receiving palliative dialysis care. Past studies have indicated
hospice services were underutilized by dialysis patients, leading to increased
Medicare costs associated with more frequent hospitalization and in hospital
death. A recent article published in the American Journal of Kidney disease
highlights the difficulty patients and families experience when faced with the
decision between dialysis and palliative care and shows that differences in
decision making for withdrawing dialysis may also be attributed to cultural
beliefs and customs. Allowing dialysis patients to enter hospice, while
continuing to receive dialysis, enables the patient to ultimately make the
decision about withdrawing from dialysis in a care setting designed to
facilitate psychological support and comfort at the end of life. (Submitted
by: National Kidney Foundation)
- ASN supports this in concept, although believes this measure must clearly
define ëwithdrawalí as well as define how inpatient (hospital level) vs
outpatient and sub-acute facilities are accounted for in the denominator and
numerator, respectively. We would be pleased to work with CMS to develop
precise definitions for use in a measure like this.(Submitted by: American
Society of Nephrology (ASN))
- RPA supports this inclusion of this measure, as 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 patientís
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. The measure meets the National Quality Strategy priorities of clinical
processes/effectiveness, patient and family engagement, and efficient use of
healthcare resources. The vast majority of patients with CKD die in acute care
facilities, without accessing palliative care services. Questions around the
issue of advance care planning showed that patients are comfortable discussing
end-of-life issues with both family (69.7%) and nephrology staff (65.6%)
However, 90.4% of patients reported that their nephrologist had not discussed
prognosis with them, and only 38.2% had completed a personal directive. Most
of the patients (51.9%) reported not having had discussion regarding end-of
life care preferences in the past 12 months, with less than 10% having had
such a discussion with their nephrologist. Almost 50% of patients wanted to
have these discussions with their nephrologist, 39% with their family doctor,
and 20% wanted to involve their nephrology nurse. Patients felt that these
discussions should be ongoing when the need arose (as defined by the medical
team). [Source: Davison SN. End-of-Life Care Preferences and Needs:
Perceptions of Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 5:
195-204, 2010.] RPA notes that two related measures MUC-182 - Adult Kidney
Disease: Discussion of Advance Care Planning and MUC-183 Adult Kidney Disease:
Advance Directives Completed were submitted during the open call for measures,
but were not selected for MAP review. This measure, along with those noted
above, is available for reporting in the RPA Kidney Quality Improvement
Registry, a CMS-approved QCDR. This registry collects data for the purpose of
patient and disease tracking to foster improvement in the quality of care
provided to patients. (Submitted by: Renal Physicians Association
)
- [Pre-workgroup meeting comment] ASN supports this in concept,
although believes this measure must clearly define ëwithdrawalí as well as
define how inpatient (hospital level) vs outpatient and subacute facilities
are accounted for in the denominator and numerator, respectively. We would be
pleased to work with CMS to develop precise definitions for use in a measure
like this.(Submitted by: American Society of Nephrology (ASN))
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3733) |
- ASN supports this concept, but does not support this as a concept measure
as this is already required as a function of the Conditions for Coverage and
worries that this measure may actually be less flexible than the CfCs when it
comes to potentially complex family dynamics, particularly among older
adolescents. As such, ASN agrees with NQF that this measure should be fully
developed before it comes up for consideration.(Submitted by: American Society
of Nephrology (ASN))
- RPA supports this inclusion of this measure, as advance 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 advance 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
patientís wishes and agrees to make decisions according to these wishes.
Ongoing discussions that include reestablishing goals of care based on the
childís response to medical treatment and optimal quality of life is the
mechanism by which advance 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. The
measure meets the National Quality Strategy priorities of clinical
processes/effectiveness, patient and family engagement, and efficient use of
healthcare resources. This measure is available for reporting in the RPA
Kidney Quality Improvement Registry, a CMS-approved QCDR. The RPA registry
collects data for the purpose of patient and disease tracking to foster
improvement in the quality of care provided to patients. (Submitted by: Renal
Physicians Association )
- [Pre-workgroup meeting comment] ASN supports this concept, but does
not support this as a concept measure as this is already required as a
function of the Conditions for Coverage and worries that this measure may
actually be less flexible than the CfCs when it comes to potentially complex
family dynamics, particularly among older adolescents.(Submitted by: American
Society of Nephrology (ASN))
| (Program: Medicare Shared Savings Program; MUC ID:
X3735) |
- We agree that shared decision making is an important tool for clinicianís
and patients and also encourage their development. In addition we recommend
expanding this tool beyond interventional procedures to include treatment
choices and treatment goals. Also, the numerator definition appears to be a
description more of ìinformed consentî rather than ìshared decision making.î
It may be of value to edit the numerator statement with language that is
consistent with a shared decision making process. (Submitted by: Johnson &
Johnson Health Care Systems Inc.)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3739) |
- The American College of Radiology supports this measure as
recommended.(Submitted by: American College of Radiology)
- We support NQF's comment that this measure should compare survey results
before and after, not simply whether a survey was administered. (Submitted by:
Press Ganey Associates)
- The ACS supports the MAP Clinician Workgroupís recommendation of for
continued development of this measure for inclusion in PQRS, Physician
Compare, and VBPM. This measure is a relevant and meaningful measure for
vascular surgeons and general surgeons who perform abdominal procedures. The
measure could also be reported by rural surgeons.(Submitted by: The American
College of Surgeons)
| (Program: Medicare Shared Savings Program; MUC ID: X3740)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3740)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID: X3741)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3741)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID: X3742)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3742)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID: X3743)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3743) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3744) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings
Program; MUC ID: X3745) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3745) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID: X3746)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3746) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings
Program; MUC ID: X3747) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3747) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- The American College of Radiology supports this measure as
recommended.(Submitted by: American College of Radiology)
- We strongly agree that this measure needs further development and
validation prior to implementation in public reporting or value-based payment
programs. We urge the MAP to make it clearer in their remarks that CMS should
defer adoption of this measure until this work can be completed. In
particular, we are concerned that the door-to-puncture (DTP) target time of
less than 120 minutes may be too long and could have the unintended
consequence of encouraging stagnation, resulting in poorer outcomes. The
biology suggests that the longer the delay between arrival and puncture time,
the worse the outcome. Although we do not know the absolute upper limit, we
do know that the shorter the DTP time, the better, therefore, providers should
always strive for the shortest possible DTP time. The optimal DTP time could
be less than 120 minutes, but may even be less than 90 minutes. We are also
concerned that few facilities will have a sufficiently high volume of patients
to yield stable and reliable estimates of performance. Although detailed
specifications were not provided for review, we would also encourage the
developers to carefully consider how transfers should be handled (i.e.,
excluded or tracked separately), since many aspects of care at the referring
hospital or in transport of the patient are outside the control of the
receiving hospital, including the referring hospitalís recognition of stroke,
distance from the receiving hospital, weather, traffic, and mode of transport.
Holding receiving facilities accountable to the same standard as for
non-transfer patients could also lead to poorer outcomes due to risk
avoidance. Finally, we would ask the MAP to reconsider its recommendation that
this measure be rolled up into a composite. Given that there is still
considerable opportunity for improvement on this metric and significant
potential for improving outcomes by decreasing DTP time, we believe focusing
on it individually rather than making it a component of a summary score will
provide clearer and more actionable information to target quality improvement
efforts. (Submitted by: American Heart Association/American Stroke
Association)
- ï We appreciate CMSí recognition of treatment times for acute ischemic
stroke as reflected by an ìunder 2 hour door-to-puncture time for endovascular
stroke treatmentî. ï However, without clarifying which patients would be
included in this measure, it is possible that IV tPA may be overlooked as
first-line treatment for eligible patients (Class I, Level of Evidence A).
ï Specifically, we suggest adding additional details about qualifying
patients, such as ìpatients in whom IV tPA is likely to fail, are excluded
from IV tPA treatment, or who present with large vessel occlusions directly
detectible by brain imagingî. (Submitted by: Genentech)
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Medicare Shared Savings
Program; MUC ID: X3750) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3750) |
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID: X3751)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3751)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID:
X3752) |
- AUGS disagrees with the MAP recommendation of conditional support for this
measure and that is should only be included in PQRS, VBM, etc. as part of a
composite measure. This is a brand new measure that was only recently
approved by the NQF and it has not yet been included in the PQRS, VBM, etc.
We believe that it first needs to be included in those programs as a single
measure and that then in further years, at the time of maintenance, it could
be considered for a composite measure. AUGS would recommend that this be
supported unconditionally and that the MAP should recommend that this measure
be included in the PQRS, VBM for 2016 reporting. This is a specialty area
with very few measures and this measure needs to be supported by the MAP
Process.(Submitted by: American Urogynecologic Society)
- The AUA supports the unconditional use of this measure for the Medicare
Shared Savings Program. This measure should not yet be rolled up into a
composite measure for pelvic surgery until the measure has been in use for
several years.(Submitted by: American Urological Association)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3752) |
- The AUA supports the inclusion of this measure in PQRS/Physician
Compare/Physician Feedback/VBPM. However, the suggestion for a composite
measure should be considered only after this measure has been in use for
several years.(Submitted by: American Urological Association)
- AUGS disagrees with the MAP recommendation of conditional support for this
measure and that is should only be included in PQRS, VBM, etc. as part of a
composite measure. This is a brand new measure that was only recently
approved by the NQF and it has not yet been included in the PQRS, VBM, etc.
We believe that it first needs to be included in those programs as a single
measure and that then in further years, at the time of maintenance, it could
be considered for a composite measure. AUGS would recommend that this be
supported unconditionally and that the MAP should recommend that this measure
be included in the PQRS, VBM for 2016 reporting. This is a specialty area
with very few measures and this measure needs to be supported by the MAP
Process.(Submitted by: American Uorgynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3754)
|
- The American College of Radiology supports this measure as
recommended.(Submitted by: American College of Radiology)
- The ACS supports the MAP Clinician Workgroups recommendation of for
continued development of this measure for inclusion in PQRS, Physician
Compare, and VBPM. This measure is a relevant and meaningful measure for
vascular surgeons. (Submitted by: The American College of
Surgeons)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3755) |
- The American College of Radiology supports this measure as
recommended.(Submitted by: American College of Radiology)
- The ACS supports the MAP Clinician Workgroupís recommendation of for
continued development of this measure for inclusion in PQRS, Physician
Compare, and VBPM. This measure is a relevant and meaningful measure for
vascular surgeons.(Submitted by: The American College of
Surgeons)
| (Program: Medicare Shared Savings
Program; MUC ID: X3756) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- This measure, under consideration for the MSSP, evaluates patients with
90-day mRS score of 0 to 2 post endovascular stroke intervention. The AANS and
CNS agree with the MAPís recommendation to ìencourage continued development,î
since in its current form it could penalize centers that receive more severe
cases. We recommend the measure developers consider some exclusions or more
specific inclusion criteria. For example, perhaps only include those patients
who have a known historical mRS of 0 or 2 pre-stroke (or alternatively,
exclude those with mRS 3 or greater). It simply makes no sense to include
patients that were debilitated prior to their stroke in a measure like this.
Other important factors to consider for risk adjustment include last known
normal, initial NIHSS, and transfer status. Higher NIHSS and a longer time to
treatment both negatively impact uncorrected outcomes. As a result,
destination centers for severe strokes could be unfairly penalized if this
critical information is not considered. For all of the stroke-related
measures, accounting for baseline patient data (NIHSS, comorbidities, time
from symptom onset to ED, etc.) and performing risk stratifications are
critical processes that will help ensure the accuracy of performance
comparisons.(Submitted by: American Association of Neurological
Surgeons/Congress of Neurological Surgeons)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3756) |
- AdvaMed supports the MAP recommendation for continued development of this
measure and agrees that the measure should be fully developed and reviewed by
NQF to ensure the measure is scientifically sound for use for national public
reporting and accountability programs before being implemented. We wanted to
highlight that appropriate risk adjustment is critical and feedback from the
relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be helpful as
this measure continues through the development/endorsement process.(Submitted
by: AdvaMed)
- The American College of Radiology supports this measure as
recommended.(Submitted by: American Collge of Radiology)
- We agree with the MAPís assessment that this measure requires further
development. It should not be included in CMS programs until it is fully
specified and validated. Achieving a modified Rankin Score (mRS) of 0 to 2 at
90 days post endovascular stroke intervention is a worthy goal, however, we
agree that, in order for this measure to provide meaningful information to
consumers or providers, it must be risk adjusted, preferably using a
risk-adjustment model that incorporates initial stroke score (e.g., NIHSS) and
age, among other key variables. We would also recommend that the developer
exclude patients with a pre-stroke mRS greater than 2 or consider a separate
outcome criterion for these patients of return to pre-stroke mRS or better.
(Submitted by: American Heart Association/American Stroke
Association)
- ï We acknowledge the importance of reporting long-term outcomes for acute
ischemic stroke, regardless of the therapeutic approach taken, and agree that
mRS is the relevant measure. We further appreciate MAPís inclusion of the
requirement for evaluator certification in order to administer the mRS.
ï However, because of the difficulties with collecting a 90-day outcome
measures such as the mRS, we encourage MAP to consider pilot-testing this
measure to include a validity/reliability assessment and adjustments for
stroke severity. ï We further encourage MAP to consider reporting both mRS 0-1
(no limitations in performing previous activities) as well as mRS 0-2 since an
mRS score of 2 reflects limitations in the patientís ability to carry out all
previous activities. (Submitted by: Genentech)
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] Support pending NQF Endorsement. We
wanted to highlight that appropriate risk adjustment is critical and feedback
from the relevant physician/disease groups (SIR/AANS/CNS/AHA/ASA/etc. may be
helpful as this measure continues through the development/endorsement
process.(Submitted by: AdvaMed)
| (Program: Medicare Shared Savings
Program; MUC ID: X3758) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy, and the
American College of Gastroenterology will work together to align and harmonize
MUC list measures X3769 (Unnecessary Screening Colonoscopy in Older Adults)
and X3758 (Appropriate Age for Colorectal Cancer Screening). AGA, ASGE and
ACG have implemented different, but similar, measures within several
registries and will work toward aligning and harmonizing these two measures,
if possible(Submitted by: American Gastroenterological
Association)
- [Pre-workgroup meeting comment] ASGE has noted that a measure
similar in concept to our societyís measure submission, specifically
Unnecessary Screening Colonoscopy in Older Adults (X3769), is included on the
current MUC list. Since these measures share the same goal, we look forward to
working with the measure developer AGA to harmonize the measure concept and
specifications. Further we recognize other interested stakeholders, notably
the American College of Gastroenterology, should be included in these
discussions.(Submitted by: American Society for Gastrointestinal
Endoscopy)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3758) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The ACG welcomes the opportunity to
work with the AGA, ASGE, and other interested stakeholders to align and
improve this proposed measure so that patient-individualization, as well as
other factors/comorbidities besides age, is considered. (Submitted by:
American College of Gastroenterology)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy, and the
American College of Gastroenterology will work together to align and harmonize
MUC list measures X3769 (Unnecessary Screening Colonoscopy in Older Adults)
and X3758 (Appropriate Age for Colorectal Cancer Screening). AGA, ASGE and
ACG have implemented different, but similar, measures within several
registries and will work toward aligning and harmonizing these two measures,
if possible(Submitted by: American Gastroenterological
Association)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3759) |
- 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. here 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. (Submitted by: American
College of Radiology)
- [Pre-workgroup meeting comment] The measure specifications have
been modified to change the size of lesions on which the measure focuses as
follows: - liver lesion < 0.5 cm - cystic kidney lesion < 1.0 cm -
adrenal lesion < 1.0 cm (Submitted by: American COllege of
Radiology)
| (Program: Medicare Shared Savings Program; MUC
ID: X3760) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy, and the
American College of Gastroenterology will work together to align and harmonize
MUC list measures X3769 (Unnecessary Screening Colonoscopy in Older Adults)
and X3758 (Appropriate Age for Colorectal Cancer Screening). AGA, ASGE and
ACG have implemented different, but similar, measures within several
registries and will work toward aligning and harmonizing these two measures,
if possible(Submitted by: American Gastroenterological
Association)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy and the
American College of Gastroenterology (AGA / ASGE / ACG) will work together to
align and harmonize MUC list measure X3760 (Frequency of inadequate bowl
preparation).(Submitted by: American Gastroenterological
Association)
- [Pre-workgroup meeting comment] ASGE has been approached by
interested stakeholders to discuss the specifications of this measure and ASGE
looks forward to convening a group to gain consensus on the
specifications.(Submitted by: American Society for Gastrointestinal
Endoscopy)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3760) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The ACG welcomes the opportunity to
work with the ASGE and other interested stakeholders in aligning and improving
this proposed measure, including whether there should be exclusions and
limitations on the patientís age and/or type of colonoscopy
performed.(Submitted by: American College of Gastroenterology)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy and the
American College of Gastroenterology (AGA / ASGE / ACG) will work together to
align and harmonize MUC list measure X3760 (Frequency of inadequate bowl
preparation).(Submitted by: American Gastroenterological
Association)
| (Program: Medicare Shared Savings Program; MUC
ID: X3761) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy and the
American College of Gastroenterology (AGA / ASGE / ACG) will work together to
align and harmonize MUC list measure X3761 (Photodocumentation of cecal
intubation).(Submitted by: American Gastroenterological
Association)
- [Pre-workgroup meeting comment] ASGE has been approached by
interested stakeholders to discuss the specifications of this measure and ASGE
looks forward to convening a group to gain consensus on the
specifications.(Submitted by: American Society for Gastrointestinal
Endoscopy)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3761) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The ACG welcomes the opportunity to
work with the ASGE and other interested stakeholders in aligning and improving
this proposed measure, including whether there should be exclusions and
limitations on the patientís age and/or type of colonoscopy
performed.(Submitted by: American College of Gastroenterology)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy and the
American College of Gastroenterology (AGA / ASGE / ACG) will work together to
align and harmonize MUC list measure X3761 (Photodocumentation of cecal
intubation).(Submitted by: American Gastroenterological
Association)
| (Program:
Medicare Shared Savings Program; MUC ID: X3763) |
- Thyroid nodules are common, with estimates of prevalence as high as 50% .
Studies have 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. A review of literature 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.(Submitted by: American College of
Radiology)
| (Program: Medicare Shared Savings
Program; MUC ID: X3764) |
- The American College of Radiology support this measure as
recommended.(Submitted by: American College of Radiology)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3764) |
- [Pre-workgroup meeting comment] ACEP appreciates the opportunity to
comment on this measure. ACEP applauds CMS for including this measure for
several Federal quality reporting programs. ACEP will be providing the annual
update for this NQF endorsed measure in early 2015. ACEP also intends to
include this measure for reporting via clinical data registry. We look forward
to continuing to promote the highest quality of emergency care and to
optimized patient exposures to ionizing radiation.(Submitted by: American
College of Emergency Physicians (ACEP) Quality and Performance
Committee)
| (Program:
Medicare Shared Savings Program; MUC ID: X3765) |
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3765) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings
Program; MUC ID: X3766) |
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3766) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings Program; MUC ID: X3768)
|
- [Pre-workgroup meeting comment] The proposed measure is based on
flawed science and will yield meaningless results due to the following
reasons: First is that the measure includes women who have contraindications
for vaginal birth such as placenta previa, fetal distress prior to labor and
medical contraindications for labor. An increase or decrease in women with
these diagnoses can significantly affect the outcome of the measure resulting
in an inaccurate measure of the effect that the obstetrical care provider has
on the risk for a cesarean birth. Second is that the measure assumes that
all nulliparous women with a term single fetus in the vertex position (NTSV)
have the same risk for cesarean birth. However, there are several physical
characteristics of the mother and her baby that have been previously proven to
SIGNIFICANTLY affect the risk for a cesarean birth. These include maternal
age, newborn weight, maternal initial body mass index, maternal height,
maternal weight gain and gestational age. In addition, induction of labor has
also been previously proven to significantly increase the risk for a cesarean
birth. Failure to provide any risk adjustment for all of these previously
proven risk factors will result in a misleading measure for obstetrical care
providers. For example, obstetrical care providers who care for women with
gestational diabetes may have patients who are heavier, carrying bigger
babies, have gained more weight and will be more likely to have a medical
indication for induction of labor. These providers, under this measure, will
be assigned a measure that is worse than it should be because the measure does
not provide any risk adjustment for these previously proven risk factors.
THIRD AND MOST IMPORTANT is the fact that a cesarean birth measure that
ignores the physical characteristics of the women who are giving birth will
yield results that are dependent on the risk applied by the physical
characteristics of the women in the target population rather than a measure of
the risk applied by the obstetrical care provider. Lastly, the goal of a
cesarean birth measure is to measure the risk applied by the obstetrical care
provider. The accuracy of a cesarean birth measure is best proven by its
ability to predict future outcomes. This measure does not provide this type
of validation. A measure that cannot accurately predict future outcomes is
merely an educated guess of the risk applied and not truly a measure.
Therefore, this measure may do more harm than good. (Submitted by:
Birthrisk.com, LLC.)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3768) |
- [Pre-workgroup meeting comment] The proposed measure is based on
flawed science and will yield meaningless results due to the following
reasons: First is that the measure includes women who have contraindications
for vaginal birth such as placenta previa, fetal distress prior to labor and
medical contraindications for labor. An increase or decrease in women with
these diagnoses can significantly affect the outcome of the measure resulting
in an inaccurate measure of the effect that the obstetrical care provider has
on the risk for a cesarean birth. Second is that the measure assumes that
all nulliparous women with a term single fetus in the vertex position (NTSV)
have the same risk for cesarean birth. However, there are several physical
characteristics of the mother and her baby that have been previously proven to
SIGNIFICANTLY affect the risk for a cesarean birth. These include maternal
age, newborn weight, maternal initial body mass index, maternal height,
maternal weight gain and gestational age. In addition, induction of labor has
also been previously proven to significantly increase the risk for a cesarean
birth. Failure to provide any risk adjustment for all of these previously
proven risk factors will result in a misleading measure for obstetrical care
providers. For example, obstetrical care providers who care for women with
gestational diabetes may have patients who are heavier, carrying bigger
babies, have gained more weight and will be more likely to have a medical
indication for induction of labor. These providers, under this measure, will
be assigned a measure that is worse than it should be because the measure does
not provide any risk adjustment for these previously proven risk factors.
THIRD AND MOST IMPORTANT is the fact that a cesarean birth measure that
ignores the physical characteristics of the women who are giving birth will
yield results that are dependent on the risk applied by the physical
characteristics of the women in the target population rather than a measure of
the risk applied by the obstetrical care provider. Lastly, the goal of a
cesarean birth measure is to measure the risk applied by the obstetrical care
provider. The accuracy of a cesarean birth measure is best proven by its
ability to predict future outcomes. This measure does not provide this type
of validation. A measure that cannot accurately predict future outcomes is
merely an educated guess of the risk applied and not truly a measure.
Therefore, this measure may do more harm than good. (Submitted by:
Birthrisk.com, LLC.)
| (Program: Medicare Shared Savings
Program; MUC ID: X3769) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] ASGE submitted to CMS a measure
entitled Appropriate Age for Colorectal Cancer Screening (X3758), which is
included on the current MUC list. This measure shares the goal of ASGE's
measure and as such, we look forward to working with the measure developer AGA
to harmonize the measure concept and specifications. Further we recognize
other interested stakeholders, notably the American College of
Gastroenterology, should be included in these discussions.(Submitted by:
American Society for Gastrointestinal Endoscopy)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3769) |
- The ACS strongly supports the development of a colonoscopy composite
measure for the four following measures to be included in PQRS/Physician
Compare/Physician Feedback/VBPM, and the Medicare Shared Saving Program
(MSSP): ï X3761 - Photodocumentation of cecal intubation ï X3760 - Frequency
of inadequate bowel preparation ï X3758 - Appropriate age for colorectal
cancer screening ï X3769 - Unnecessary Screening Colonoscopy in Older Adults
Colonoscopy is the second most common procedure for general surgery. As a
high-value composite measure, this will encompass appropriate use of imaging,
screening and surveillance, and resource use. This composite measure would
reportable by colorectal surgeons and general surgeons who perform abdominal
procedures and would fill a critical measurement gap. (Submitted by: The
American College of Surgeons)
- [Pre-workgroup meeting comment] The ACG welcomes the opportunity to
work with the AGA, ASGE, and other interested stakeholders to align and
improve this proposed measure so that patient-individualization, as well as
other factors/comorbidities besides age, is considered. (Submitted by:
American College of Gastroenterology)
- [Pre-workgroup meeting comment] The American Gastroenterological
Association, the American Society of Gastrointestinal Endoscopy, and the
American College of Gastroenterology will work together to align and harmonize
MUC list measures X3769 (Unnecessary Screening Colonoscopy in Older Adults)
and X3758 (Appropriate Age for Colorectal Cancer Screening). AGA, ASGE and
ACG have implemented different, but similar, measures within several
registries and will work toward aligning and harmonizing these two measures,
if possible(Submitted by: American Gastroenterological
Association)
| (Program:
Medicare Shared Savings Program; MUC ID: X3770) |
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3770) |
- The AAN feels that this is a significant issue for primary headache
disorder patients and should be considered as a disorder specific
measure.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings Program;
MUC ID: X3771) |
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3771) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings Program;
MUC ID: X3772) |
- Amgen supports MUC X3772 ìPreventive Migraine Medication Prescribedî for
inclusion in the CMS quality programs for clinicians. Amgen supports
performance measures that encourage migraine prevention, diagnosis, and
treatment. There are significant unmet needs in the prevention of migraines,
and diagnosis and treatment rates are low. Although there are current
treatment options, the majority of patients discontinue therapy within one
year of initiation. This measure will help improve the quality of care for
the more than 36 million people in the US that suffer from this disabling
condition (American Migraine Foundation). (Submitted by: Amgen)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3772) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- Amgen supports MUC X3772 ìPreventive Migraine Medication Prescribedî for
inclusion in the CMS quality programs for clinicians. Amgen supports
performance measures that encourage migraine prevention, diagnosis, and
treatment. There are significant unmet needs in the prevention of migraines,
and diagnosis and treatment rates are low. Although there are current
treatment options, the majority of patients discontinue therapy within one
year of initiation. This measure will help improve the quality of care for
the more than 36 million people in the US that suffer from this disabling
condition (American Migraine Foundation). (Submitted by: Amgen)
- Amgen supports MUC X3772 ìPreventive Migraine Medication Prescribedî for
inclusion in the CMS quality programs for clinicians. Amgen supports
performance measures that encourage migraine prevention, diagnosis, and
treatment. There are significant unmet needs in the prevention of migraines,
and diagnosis and treatment rates are low. Although there are current
treatment options, the majority of patients discontinue therapy within one
year of initiation. This measure will help improve the quality of care for
the more than 36 million people in the US that suffer from this disabling
condition (American Migraine Foundation). (Submitted by: Amgen)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Medicare Shared Savings Program; MUC ID: X3773)
|
- "1. Consider changing age range to ìpatients =5 yearsî; Given the
exclusion of COPD and other lung disorders there is no need to restrict the
upper age limit to 50 years. 2. Recommend changing ìNumber of emergency
department visits not resulting in a hospitalization due to asthma in last 12
monthsî to ìNumber of emergency department visit due to asthma, that did not
result in hospitalization, in the last 12 monthsî. 3. Consider including
ìNumber of asthma exacerbations requiring oral systemic corticosteroids less
than 2 times in the last 12 monthsî in the Numerator. " (Submitted by:
AstraZeneca Pharmaceuticals)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3773)
|
- This measure has the potential to add value in terms of getting some
standard practice of asthma control measurement on a regular basis using a
validated tool such as an asthma control test. It would also get some measure
of how often an individual with asthma is utilizing acute care services within
a given practice within a given time frame. It encompasses most of the ages,
although would be nice to extend to 2 years. It will likely encourage
increased evaluation and prescription for controller medication and second to
that compliance and follow up observation whether by phone or visit (increase
use of primary over acute care). It may also allow providers to more
effectively find out the group of patients who do require more close follow up
and attention and target innovative or group interventions for them (80/20
rule). Some electronic medical records (EMR) systems integrate the asthma
control test; EMRs also contain asthma action plans and could create fields
for self-reporting of use of acute care. There would be some burden in
extracting this data and reporting it, depending on the infrastructure of the
facility. This is so variable it would be hard to comment in general. This
measure fills a gap. NQF 0036 addresses appropriate medications but does not
address the more optimal management of an asthma patient including a home
management plan of care, assessment of control and acute care utilization.
Hard to understand what exactly this measure would entail. Might be better to
break down into 1) presence of asthma care plan 2) assessment of control 3)
medication utilization 4) primary care revisits 5) ER visits. (Submitted by:
American Academy of Pediatrics)
- While the American Academy of Allergy Asthma and Immunology (AAAAI) is
supportive of the intent of the Optimal Asthma Care measure, we believe that
it needs to be improved before further use in federal programs, and that it
should NOT be adopted if the upper age limit is left unchanged. The current
proposed upper age limit of 50 years of age in the Optimal Asthma Care measure
is unwarranted by the evidence and ignores the ever-increasing population of
older asthma patients in quality reporting programs. We believe that there is
significant misunderstanding of the importance of asthma measures for older
patients. As reported in a March 2013 study in the Journal of Allergy and
Clinical Immunology: In Practice, older adults with asthma have worse quality
of life, asthma control and increased health care utilization than their
peers. (Quality of Life, Health Care Utilization, and Control in Older Adults
with Asthma, Ross et al, J ALLERGY CLIN IMMUNOL: IN PRACTICE, March 2013).
More than 50% of all deaths due to asthma occur in patients over 65 years old,
and many patients develop and are diagnosed with asthma after the age of 40.
Many older asthma patients suffer with severe asthma, and this should no
longer be ignored by CMS and others in the quality sphere. Approval of this
measure as presented with an unsupported and arbitrary age limit will result
not only in failing to capture an important population and the very group of
patients that the PQRS was initially authorized to target, but indeed
reinforces the lack of understanding of the seriousness of asthma in older
patients. The AAAAI and other specialty-related organizations have argued
against inappropriate age limits for years, and this measure including this
age limit of 50 represents a serious step backwards in extending quality
initiatives to cover older asthma patients. It is inconsistent with the
direction of current asthma quality measures as the upper age limit in PQRS
measure 53 (NQF 0047), Asthma Pharmacologic Therapy for Persistent Asthma ñ
Ambulatory Care Setting, has been removed for 2015 PQRS reporting. Further,
during the development of the AMA-PCPI Asthma Measures Set, workgroup members
unanimously recommended that the measures not include an upper age limit as it
unnecessarily eliminates the aging asthma population. Therefore, removal of
this upper age limit will also improve consistency and harmonization with
existing asthma measures in CMS programs, as well as to encourage better
asthma care. Further, as allergist/immunologists, members of our specialty
provide care to patients with more severe asthma, and the Optimal Asthma Care
measure as currently construed does not allow for risk adjustment for
severity. We feel strongly that methods of risk adjustment can and should be
applied to adjust for this important factor. We believe that there may be
several ways to improve this measure with the inclusion of risk adjustment
factors, such as medication use or responsiveness to treatment. The A/I
specialty would be pleased to work with the measure steward (Minnesota
Community Measurement) to help develop an appropriate risk adjustment strategy
in a timely manner to facilitate the measure advancing in an improved form
next year. Finally, we believe the measure could be improved by amending it to
include a substantial improvement in asthma control during the measurement
period as being numerator compliant. A substantial change could be defined
based on per cent improvement (e.g. 20 %) or based on the minimal important
difference (MID) of the instrument (3 for ACT and 0.5 for ACQ). Patients with
more severe asthma may improve substantially with appropriate treatment but
still not reach the well-controlled level. If the measure were to also capture
a meaningful improvement in ACT scores over time, it would still reward
appropriate care but also make the measure less severity-dependent. The AAAAI
supports Minnesota Community Measurementís efforts to create an outcomes
measure and encourages continued efforts to make the Optimal Asthma Care
measure more meaningful to the asthma patient population. Indeed the AAAAI is
already using the measure (with permission, and without an upper age limit of
course) in its CMS approved Qualified Clinical Data Registry. However, there
is significant need for improvement in the measure before it is applied more
broadly, particularly on account of this unsupported and outdated upper age
limit. We sincerely think it is not just limiting the measure's applicability,
but that indeed it sends an absolute wrong and potentially damaging message to
providers about the care of older asthma patients. The AAAAI thanks the NQF
and the MAP for allowing preliminary comments to be submitted this year, prior
to the MAP deliberations. We are also anxious to hear how CMS chooses to
interpret "conditional support" vs. "encourage further development." Finally,
we sincerely appreciate the opportunity to participate in this comment period
to address these very important measures. (Submitted by: American Academy
of Allergy, Asthma & Immunology )
- [Pre-workgroup meeting comment] While the American Academy of
Allergy Asthma and Immunology (AAAAI) is supportive of the intent of the
Optimal Asthma Care measure, we have several concerns regarding its use as
currently specified and recommendations on how to improve it. We request that
modifications be considered to the measure before it is given NQF approval.
First, the current proposed upper age limit of 50 years of age in the Optimal
Asthma Care measure is unwarranted. We strongly encourage the removal of this
upper age limit in order to include the ever-increasing population of older
asthma patients in quality reporting programs. Approval of this measure as
presented with an unsupported and arbitrary age limit will result in the
failure of capturing an important population and the very group of patients
that the PQRS was initially authorized to target. This is a serious step
backwards in extending quality initiatives to cover older asthma patients and
is inconsistent with the direction of current asthma quality measures. The
upper age limit of PQRS measure 53 (NQF 0047), The Asthma Pharmacologic
Therapy for Persistent Asthma ñ Ambulatory Care Setting, has been removed for
2015 PQRS reporting. Further, during the development of the AMA-PCPI Asthma
Measures Set, workgroup members unanimously recommended that the measures not
include an upper age limit as it unnecessarily removed the aging asthma
population. In order to ensure consistency and harmonization with existing
asthma measures, we recommend the removal of the upper age limit of 50 on the
Optimal Asthma Care measure. In addition, as allergist/immunologists, members
of our specialty provide care to patients with more severe asthma, and the
Optimal Asthma Care measure as currently construed does not allow for risk
adjustment for severity. We feel strongly that methods of risk adjustment can
and should be applied to adjust for this important factor. We believe that
there may be several ways to improve this measure with the inclusion of risk
adjustment factors, such as medication use or responsiveness to treatment. The
A/I specialty would be pleased to work with the measure steward (Minnesota
Community Measurement) to help develop an appropriate risk adjustment strategy
in a timely manner to facilitate the measure advancing in an improved form
next year. Finally, we believe the measure could be improved by amending it to
include a substantial improvement in asthma control during the measurement
period as being numerator compliant. A substantial change could be defined
based on per cent improvement (e.g. 20 %) or based on the minimal important
difference (MID) of the instrument (3 for ACT and 0.5 for ACQ). Patients with
more severe asthma may improve substantially with appropriate treatment but
still not reach the well-controlled level. If the measure were to also capture
a meaningful improvement in ACT scores over time, it would still reward
appropriate care but also make the measure less severity-dependent. The AAAAI
supports Minnesota Community Measurementís efforts to create an outcomes
measure and encourages continued efforts to make the Optimal Asthma Care
measure more meaningful to the asthma patient population. Indeed the AAAAI is
already using the measure in its CMS approved Qualified Clinical Data
Registry. However, there is significant need for improvement in the measure
before it be applied more broadly, a need highlighted by the use of an
unsupported and outdated upper age limit. (Submitted by: American Academy of
Allergy Asthma and Immunology)
- [Pre-workgroup meeting comment] We have concerns regarding the
measure and recommend the following changes for consideration. First, the
ability to capture asthma exacerbations would likely improve if an additional
exacerbation definition was added: based on oral corticosteroids (OCS) burst
of =15 days (in addition to hospitalizations and ER visits). Second, because
OCS are associated with negative adverse events, it may be helpful to evaluate
the % of patients who receive high doses of OCS (e.g., in
prednisone-equivalent exposure) for future changes to the measure. Third,
because medications (especially controllers) are important in asthma
management, we suggest adding asthma medication ratio (AMR) measures to the
panel of process and outcomes measures comprised so far.(Submitted by:
Genentech)
| (Program: Medicare Shared Savings
Program; MUC ID: X3774) |
- This measure looks at all patients 18 and older prescribed opiates for
longer than six weeks duration who are 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. In
regards to the Medicare Shared Savings Program, the MAP offered ìconditional
supportî noting that it would support this measure only if it were rolled up
into a composite measure for chronic opioid use. The MAP also considered this
measure for multiple physician-directed programs, such as the PQRS,
Value-Modifier, and Physician Compare. The MAP recognizes that this measure
addresses the important area of chronic opioid use, which has yet to be
addressed in these programs, and addresses the tension between pain management
and preventing abuse. Nevertheless, it is concerned about the impact that
this measure, which currently includes no exclusions, could have on palliative
care patients and feels that better measures are needed. Overall, the MAP
offered ìconditional supportî for this measure, but MAP supports that it be
included as part of a composite measure. AAHPM agrees with the MAPís
ìconditional support,î but we disagree that this measure is related only to
chronic opioid use (unless a measure related to chronic opioid use was related
also to potential or new long-term opioid use). Hospice and palliative
medicine patients are not exempt from risk for misuse and should be screened
via an expert psychosocial assessment or structured assessment tool.
(Submitted by: AAHPM)
- NASS is in support of routinely screening patients taking opiates to
determine possible issues of dependence or abuse. However, we would like to
note that the measureís definition of chronic opioid use seems short from a
spine surgeon perspective. For many patients undergoing major spinal surgery,
itís not atypical to continue opiate use longer than 6 weeks. While we
understand that the goal of the measure is to ultimately decrease opioid
dependency issues, we donít want to inadvertently label those with complex
spinal conditions and surgeries, who require opioid use longer than 6 weeks,
as misusers of opioids. Nonetheless, NASS believes that this measure is
important and offers support contingent upon either an increase in the time
threshold or the addition of an exclusion criterion for complex spinal surgery
patients. NASS would also like to note a typo in the background materials.
The Screener and Opioid Assessment for Patients with Pain-Revised test should
be listed as SOAPP-R, not SOAAP-R. (Submitted by: North American Spine
Society)
- This measure looks at all patients 18 and older prescribed opiates for
longer than six weeks duration who are 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. In
regards to the Medicare Shared Savings Program, the MAP offered ìconditional
supportî noting that it would support this measure only if it were rolled up
into a composite measure for chronic opioid use. The MAP also considered this
measure for multiple physician-directed programs, such as the PQRS,
Value-Modifier, and Physician Compare. The MAP recognizes that this measure
addresses the important area of chronic opioid use, which has yet to be
addressed in these programs, and addresses the tension between pain management
and preventing abuse. Nevertheless, it is concerned about the impact that this
measure, which currently includes no exclusions, could have on palliative care
patients and feels that better measures are needed. Overall, the MAP offered
ìconditional supportî for this measure, but MAP supports that it be included
as part of a composite measure. AAHPM agrees with the MAPís ìconditional
support,î but we disagree that this measure is related only to chronic opioid
use (unless a measure related to chronic opioid use was related also to
potential or new long-term opioid use). Hospice and palliative medicine
patients are not exempt from risk for misuse and should be screened via an
expert psychosocial assessment or structured assessment tool.(Submitted by:
American Academy of Hospice and Palliative Medicine)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3774) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- NASS is in support of routinely screening patients taking opiates to
determine possible issues of dependence or abuse. However, we would like to
note that the measureís definition of chronic opioid use seems short from a
spine surgeon perspective. For many patients undergoing major spinal surgery,
itís not atypical to continue opiate use longer than 6 weeks. While we
understand that the goal of the measure is to ultimately decrease opioid
dependency issues, we donít want to inadvertently label those with complex
spinal conditions and surgeries, who require opioid use longer than 6 weeks,
as misusers of opioids. Nonetheless, NASS believes that this measure is
important and offers support contingent upon either an increase in the time
threshold or the addition of an exclusion criterion for complex spinal surgery
patients. NASS would also like to note a typo in the background materials.
The Screener and Opioid Assessment for Patients with Pain-Revised test should
be listed as SOAPP-R, not SOAAP-R. (Submitted by: North American Spine
Society)
- ASN supports this in concept, although believes that this should apply to
the prescribing individual/practice/setting rather than to every setting in
which the patient is seen.(Submitted by: American Society of Nephrology
(ASN))
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] ASN supports this in concept,
although believes that this should apply to the prescribing
individual/practice/setting rather than to every setting in which the patient
is seen.(Submitted by: American Society of Nephrology (ASN))
| (Program: Medicare Shared Savings Program;
MUC ID: X3775) |
- This measure, under consideration for the MSSP, as well as the PQRS,
Value-Modifier, and Physician Compare, evaluates 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. For the MSSP, the MAP recommends ìconditional supportî for
this measure only if it is rolled up into a composite measure for chronic
opioid use. For the physician quality programs, the MAP recognizes that this
measure addresses an important topic that has not yet been addressed in the
PQRS, but that more specificity is needed for what is expected at the
follow-up evaluation. While the majority of prescribers maintain follow up
evaluation at least every three months during opioid therapy, we recognize
that this is not universal and can be more challenging in areas where there
are fewer clinicians and home services are less accessible. In its current
format, this measure does not state that the re-evaluation must be performed
in person, who performs it, or what it contains. In contrast to the
recommendation of the MAP, the AAHPM actually believes this measure should not
specify these elements as that could place an unreasonable burden on some of
the sicker patients who are not receiving hospice services. While we support
the measure in concept, collecting this data manually would be burdensome.
However, data collection would not create an unreasonable burden once
technology was established to track this metric. (Submitted by:
AAHPM)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3775) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- AGS agrees that this is an important measure as chronic opioids may have
cognitive and functional impairments in older adults and should be provided at
the lowest therapeutic dose required or discontinued in favor of alternative
strategies. (Submitted by: American Geriatrics Society)
- This measure, under consideration for the MSSP, as well as the PQRS,
Value-Modifier, and Physician Compare, evaluates 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. For the MSSP, the MAP recommends ìconditional supportî for
this measure only if it is rolled up into a composite measure for chronic
opioid use. For the physician quality programs, the MAP recognizes that this
measure addresses an important topic that has not yet been addressed in the
PQRS, but that more specificity is needed for what is expected at the
follow-up evaluation. While the majority of prescribers maintain follow up
evaluation at least every three months during opioid therapy, we recognize
that this is not universal and can be more challenging in areas where there
are fewer clinicians and home services are less accessible. In its current
format, this measure does not state that the re-evaluation must be performed
in person, who performs it, or what it contains. In contrast to the
recommendation of the MAP, the AAHPM actually believes this measure should not
specify these elements as that could place an unreasonable burden on some of
the sicker patients who are not receiving hospice services. While we support
the measure in concept, collecting this data manually would be burdensome.
However, data collection would not create an unreasonable burden once
technology was established to track this metric.(Submitted by: American
Academy of Hospice and Palliative Medicine)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Medicare Shared Savings
Program; MUC ID: X3776) |
- This measure looks at 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. The MAP was unable to reach consensus on this measure and does not
support it for the Medicare Shared Savings Program. The MAP also considered
this measure for multiple physician-directed programs, such as the PQRS,
Value-Modifier, and Physician Compare, but its recommendation is ìto be
determined.î While, again, this measure addresses the important area chronic
opioid use, which is currently absent from physician-level programs, this is
little more than a simple documentation measure. Consensus was not reached
because some believed the topic is important even though this is a low value
measure. AAHPM agrees with those who have concerns about this measure. While
opioids are commonly used by our members in the management of pain, and we
recognize the persistent gap in measuring this area of care, this measure has
no hope of leading to anything meaningful, other than a checkbox, and should
not be supported.(Submitted by: AAHPM)
- NASS is in support of measures that encourage shared decision making.
Although we feel that this is an important issue, we would like to note that
the measureís definition of chronic opioid use seems short from a spine
surgeon perspective. For many patients undergoing major spinal surgery, itís
not atypical to continue opiate use longer than 6 weeks. While we understand
that the goal of the measure is to ultimately decrease opioid dependency
issues, we donít want to inadvertently label those with complex spinal
conditions and surgeries, who require opioid use longer than 6 weeks, as
misusers of opioids. Nonetheless, NASS believes that this measure is
important and offers support contingent upon either an increase in the time
threshold or the addition of an exclusion criterion for complex spinal surgery
patients.(Submitted by: North American Spine Society)
- This measure looks at 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. The MAP was unable to reach consensus on this measure and does not
support it for the Medicare Shared Savings Program. The MAP also considered
this measure for multiple physician-directed programs, such as the PQRS,
Value-Modifier, and Physician Compare, but its recommendation is ìto be
determined.î While, again, this measure addresses the important area chronic
opioid use, which is currently absent from physician-level programs, this is
little more than a simple documentation measure. Consensus was not reached
because some believed the topic is important even though this is a low value
measure. AAHPM agrees with those who have concerns about this measure. While
opioids are commonly used by our members in the management of pain, and we
recognize the persistent gap in measuring this area of care, this measure has
no hope of leading to anything meaningful, other than a checkbox, and should
not be supported.(Submitted by: American Academy of Hospice and Palliative
Medicine)
- [Pre-workgroup meeting comment] agree with the addition of the 4
current PQRS measures for sleep apnea. they include; a.PQRS
measure 276: Sleep Apnea: Assessment of Sleep Symptoms b. PQRS measure 277:
Sleep Apnea: Severity Assessment at Initial Diagnosis c. PQRS measure 278:
Sleep Apnea: Positive Airway Pressure Therapy Prescribed d. PQRS measure 279:
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
(Submitted by: ResMed)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3776) |
- NASS is in support of measures that encourage shared decision making.
Although we feel that this is an important issue, we would like to note that
the measureís definition of chronic opioid use seems short from a spine
surgeon perspective. For many patients undergoing major spinal surgery, itís
not atypical to continue opiate use longer than 6 weeks. While we understand
that the goal of the measure is to ultimately decrease opioid dependency
issues, we donít want to inadvertently label those with complex spinal
conditions and surgeries, who require opioid use longer than 6 weeks, as
misusers of opioids. Nonetheless, NASS believes that this measure is
important and offers support contingent upon either an increase in the time
threshold or the addition of an exclusion criterion for complex spinal surgery
patients.(Submitted by: North American Spine Society)
- The AAN strongly encourages the MAP to consider recommending this measure
for inclusion in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Medicare Shared Savings
Program; MUC ID: X3777) |
- NASS is in support of measures that encourage shared decision making and
patient accountability. Again, we would like to note that the measureís
definition of chronic opioid use seems short from a spine surgeon perspective.
For many patients undergoing major spinal surgery, itís not atypical to
continue opiate use longer than 6 weeks. While we understand that the goal of
the measure is to ultimately decrease opioid dependency issues, we donít want
to inadvertently label those with complex spinal conditions and surgeries, who
require opioid use longer than 6 weeks, as misusers of opioids. Nonetheless,
NASS believes that this measure is important and offers support contingent
upon either an increase in the time threshold or the addition of an exclusion
criterion for complex spinal surgery patients. (Submitted by: North American
Spine Society)
- This measure looks at 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. In regards to the
MSSP, the MAP offered ìconditional supportî noting that it would support this
measure only if it were rolled up into a composite measure for chronic opioid
use. The MAP also considered this measure for multiple physician-directed
programs, such as the PQRS, Value-Modifier, and Physician Compare. While the
MAP recognizes the measure addresses the important area of chronic opioid use,
which has yet to be addressed in these programs, it agrees with the public
that there is limited evidence on the effectiveness. However, the MAP
recommended ìconditional supportî for using this measure in these programs,
based on submission to the NQF for endorsement, since a signed agreement has
been recommended by multiple societies. The MAP also believes a composite
would be appropriate for this and other opioid measures under consideration
(measures X3774, X3776, X3775). AAHPM cautions the MAP against supporting
this measure. As noted, there is no good literature to support opioid
agreements. In fact, in practice, they have been shown to potentially lead to
bad outcomes. If CMS decides to include a measure like this in any future
federal program, we would strongly urge it to at least consider appropriate
exclusions from the denominator, such as patients who the clinician believes
would be harmed by signing a formal agreement. CMS should also consider
linking this measure to X3774: Evaluation of Interview for Risk of Opioid
Misuse in order to obtain an objective read of the patientís risk
level.(Submitted by: AAHPM)
- This measure looks at 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. In regards to the
MSSP, the MAP offered ìconditional supportî noting that it would support this
measure only if it were rolled up into a composite measure for chronic opioid
use. The MAP also considered this measure for multiple physician-directed
programs, such as the PQRS, Value-Modifier, and Physician Compare. While the
MAP recognizes the measure addresses the important area of chronic opioid use,
which has yet to be addressed in these programs, it agrees with the public
that there is limited evidence on the effectiveness. However, the MAP
recommended ìconditional supportî for using this measure in these programs,
based on submission to the NQF for endorsement, since a signed agreement has
been recommended by multiple societies. The MAP also believes a composite
would be appropriate for this and other opioid measures under consideration
(measures X3774, X3776, X3775). AAHPM cautions the MAP against supporting this
measure. As noted, there is no good literature to support opioid agreements.
In fact, in practice, they have been shown to potentially lead to bad
outcomes. If CMS decides to include a measure like this in any future federal
program, we would strongly urge it to at least consider appropriate exclusions
from the denominator, such as patients who the clinician believes would be
harmed by signing a formal agreement. CMS should also consider linking this
measure to X3774: Evaluation of Interview for Risk of Opioid Misuse in order
to obtain an objective read of the patientís risk level.(Submitted by:
American Academy of Hospice and Palliative Medicine)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3777) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- NASS is in support of measures that encourage shared decision making and
patient accountability. Again, we would like to note that the measureís
definition of chronic opioid use seems short from a spine surgeon perspective.
For many patients undergoing major spinal surgery, itís not atypical to
continue opiate use longer than 6 weeks. While we understand that the goal of
the measure is to ultimately decrease opioid dependency issues, we donít want
to inadvertently label those with complex spinal conditions and surgeries, who
require opioid use longer than 6 weeks, as misusers of opioids. Nonetheless,
NASS believes that this measure is important and offers support contingent
upon either an increase in the time threshold or the addition of an exclusion
criterion for complex spinal surgery patients. (Submitted by: North American
Spine Society)
- ASN supports this in concept, and understands that chronic pain is a
concern for those with complex chronic disease. Patients on dialysis often
have their opioid use managed by their primary care or non-dialysis care
provider. The contract should be with the primary care provider or provider
that manages the pain, not the dialysis facility or subspecialist. (Submitted
by: American Society of Nephrology (ASN))
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
- [Pre-workgroup meeting comment] (Submitted by: Academy of Managed
Care Pharmacy)
- [Pre-workgroup meeting comment] ASN supports this in concept, and
understands that chronic pain is a concern for those with complex chronic
disease. Patients on dialysis often have their opioid use managed by their
primary care or non-dialysis care provider. The contract should be with the
primary care provider or provider that manages the pain, not the dialysis
facility or subspecialist.(Submitted by: American Society of Nephrology
(ASN))
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3778) |
- This measure has the potential to add value, not only by decreasing
exposure to ionizing radiation, but also through the cost savings that would
come along with decreasing scans by up to 200,000 on an annual basis.
Adherence to the actions in this measure has the potential to improve patient
outcomes through decreased radiation exposure, improved ED throughput,
increased radiology throughput, decreased cost, and avoidance of an increase
in risk of cancer. As long as a system could be created that cross-referenced
head CT's, trauma and Glasgow Coma Scale, data collection would not be
terribly burdensome. This measure would align with Choosing Wisely
recommendations. (Submitted by: American Academy of
Pediatrics)
- The American College of Radiology support this measure as
recommended.(Submitted by: American College of Radiology)
- List ticagrelor under antiplatelet agents in Exclusion section (Submitted
by: AstraZeneca Pharmaceuticals )
- [Pre-workgroup meeting comment] ACEP appreciates the opportunity to
comment on this measure. We applaud CMS for including this measure in the
Measures Under Consideration for various Federal quality reporting programs.
ACEP is committed to promoting the highest quality of emergency care and to
optimizing patient exposure to ionizing radiation for low risk pediatric
patients in the emergency department.(Submitted by: American College of
Emergency Physicians (ACEP) Quality and Performance Committee)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3780)
|
- [Pre-workgroup meeting comment] ACEP appreciates the opportunity to
comment on this measure. We applaud CMS for including this measure in the
Measures Under Consideration for various Federal quality reporting programs.
ACEP is committed to promoting the highest quality of emergency care and to
reducing unneccessary testing for low risk patients in the emergency
department. (Submitted by: American College of Emergency Physicians (ACEP)
Quality and Performance Committee)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3781) |
- The American College of Radiology support this measure as
recommended.(Submitted by: American College of Radiology)
- [Pre-workgroup meeting comment] The measure description and measure
denominator have been edited to specifically look at patients with IODINATED
contrast reactions.(Submitted by: American COllege of
Radiology)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3783) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3784) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3785)
|
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- The American College of Radiology support this measure as
recommended.(Submitted by: American College of Radiology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3786) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- We support this measure because it promotes outcomes-based,
patient-centered care. However, we caution that patient questionnaires for
assessing quality of life should be standardized across different quality of
life measures so that physician offices are more easily able to implement
measurement into their workflow. We agree that the measure should be tested at
the clinician level.(Submitted by: Press Ganey Associates)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3787)
|
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Medicare Shared Savings Program; MUC
ID: X3788) |
- [Pre-workgroup meeting comment] The proposed measure is a DISASTER
which is based on flawed science and will yield meaningless results due to the
following reasons: First is that the measure includes women who have
contraindications for vaginal birth such as placenta previa, fetal distress
prior to labor and medical contraindications for labor. An increase or
decrease in women with these diagnoses can significantly affect the outcome of
the measure resulting in an inaccurate measure of the effect that the
obstetrical care provider has on the risk for a cesarean birth. Even one or
two additional cesarean births due to these diagnoses can significantly affect
the measure as is illustrated in the third concern below. Second is that the
measure assumes that all nulliparous women with a term single fetus in the
vertex position (NTSV) have the same risk for cesarean birth after adjusting
for age. However, in addition to maternal age, there are other physical
characteristics of the mother and her baby that have been previously proven to
significantly affect the risk for a cesarean birth. These include newborn
weight, maternal initial body mass index, maternal height, maternal weight
gain and gestational age. In addition, induction of labor has also been
previously proven to significantly increase the risk for a cesarean birth.
Failure to provide any risk adjustment for all of these previously proven risk
factors will result in a misleading measure for obstetrical care providers.
For example, obstetrical care providers who care for women with gestational
diabetes may have patients who are heavier, carrying bigger babies, have
gained more weight and will be more likely to have a medical indication for
induction of labor. These providers, under this measure, will be assigned a
measure that is worse than it should be because the measure does not provide
any risk adjustment for these previously proven risk factors. THIRD AND MOST
IMPORTANT is a major flaw found in the direct standardization technique being
used to create the risk adjustment for age. The direct standardization
technique used in the measure is based on the work of Main, et al from 2006.
The flaw in the direct standardization technique is illustrated by the sample
hospital in their study. The sample hospital in their study had approximately
18,000 births over a three year period in order to create a target population
of 7,068 nulliparous term singleton vertex (NTSV) births of which only 68 were
in the 15 to 19 year old age group. This age group is assigned a weight of
21% in the direct standardization. This means that even though the sample
hospital only had 1% of their births in the 15 to 19 year old age group this
age group will be used to assign 21% of their cesarean birth measure. A small
change in the number of cesarean births within that age group will result in a
large change in their cesarean birth measure. Even with 6,000 total births
each year the sample hospital will only have two patients per month and six
patients per quarter accounting for 21% of their cesarean birth measure. This
will make it very difficult for the sample hospital to obtain consistent
results and this problem would only be magnified if the hospital had fewer
than 6,000 births per year. If a hospital has the same age distribution of
NTSV patients as the sample hospital in the study, analysis will show that one
additional cesarean birth in the 15 to 19 year old age group per 1,000 total
births this year than last year will increase their cesarean birth measure by
five percentage points. This flaw makes this measure meaningless for
hospitals that have a similar age distribution as the sample hospital in the
study. IF A HOSPITAL WITH 6,000 BIRTHS PER YEAR WILL HAVE THIS TYPE OF PROBLEM
THEN AT THE PROVIDER LEVEL THIS MEASURE IS A DISASTER! Lastly, the goal of a
cesarean birth measure is to measure the risk applied by the obstetrical care
provider. The accuracy of a cesarean birth measure is best proven by its
ability to predict future outcomes. This measure does not provide this type
of validation. A measure that cannot accurately predict future outcomes is
merely an educated guess of the risk applied and not truly a measure.
Therefore, this measure may do more harm than good. (Submitted by:
Birthrisk.com, LLC.)
| (Program: Physician Quality Reporting System
(PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3788) |
- [Pre-workgroup meeting comment] The proposed measure is a DISASTER
which is based on flawed science and will yield meaningless results due to the
following reasons: First is that the measure includes women who have
contraindications for vaginal birth such as placenta previa, fetal distress
prior to labor and medical contraindications for labor. An increase or
decrease in women with these diagnoses can significantly affect the outcome of
the measure resulting in an inaccurate measure of the effect that the
obstetrical care provider has on the risk for a cesarean birth. Even one or
two additional cesarean births due to these diagnoses can significantly affect
the measure as is illustrated in the third concern below. Second is that the
measure assumes that all nulliparous women with a term single fetus in the
vertex position (NTSV) have the same risk for cesarean birth after adjusting
for age. However, in addition to maternal age, there are other physical
characteristics of the mother and her baby that have been previously proven to
significantly affect the risk for a cesarean birth. These include newborn
weight, maternal initial body mass index, maternal height, maternal weight
gain and gestational age. In addition, induction of labor has also been
previously proven to significantly increase the risk for a cesarean birth.
Failure to provide any risk adjustment for all of these previously proven risk
factors will result in a misleading measure for obstetrical care providers.
For example, obstetrical care providers who care for women with gestational
diabetes may have patients who are heavier, carrying bigger babies, have
gained more weight and will be more likely to have a medical indication for
induction of labor. These providers, under this measure, will be assigned a
measure that is worse than it should be because the measure does not provide
any risk adjustment for these previously proven risk factors. THIRD AND MOST
IMPORTANT is a major flaw found in the direct standardization technique being
used to create the risk adjustment for age. The direct standardization
technique used in the measure is based on the work of Main, et al from 2006.
The flaw in the direct standardization technique is illustrated by the sample
hospital in their study. The sample hospital in their study had approximately
18,000 births over a three year period in order to create a target population
of 7,068 nulliparous term singleton vertex (NTSV) births of which only 68 were
in the 15 to 19 year old age group. This age group is assigned a weight of
21% in the direct standardization. This means that even though the sample
hospital only had 1% of their births in the 15 to 19 year old age group this
age group will be used to assign 21% of their cesarean birth measure. A small
change in the number of cesarean births within that age group will result in a
large change in their cesarean birth measure. Even with 6,000 total births
each year the sample hospital will only have two patients per month and six
patients per quarter accounting for 21% of their cesarean birth measure. This
will make it very difficult for the sample hospital to obtain consistent
results and this problem would only be magnified if the hospital had fewer
than 6,000 births per year. If a hospital has the same age distribution of
NTSV patients as the sample hospital in the study, analysis will show that one
additional cesarean birth in the 15 to 19 year old age group per 1,000 total
births this year than last year will increase their cesarean birth measure by
five percentage points. This flaw makes this measure meaningless for
hospitals that have a similar age distribution as the sample hospital in the
study. IF A HOSPITAL WITH 6,000 BIRTHS PER YEAR WILL HAVE THIS TYPE OF PROBLEM
THEN AT THE PROVIDER LEVEL THIS MEASURE IS A DISASTER! Lastly, the goal of a
cesarean birth measure is to measure the risk applied by the obstetrical care
provider. The accuracy of a cesarean birth measure is best proven by its
ability to predict future outcomes. This measure does not provide this type
of validation. A measure that cannot accurately predict future outcomes is
merely an educated guess of the risk applied and not truly a measure.
Therefore, this measure may do more harm than good. (Submitted by:
Birthrisk.com, LLC.)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3789) |
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommend this measure for inclusion in CMS programs.(Submitted
by: American Academy of Neurology)
| (Program: Physician Quality Reporting
System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment
Modifier; MUC ID: X3791) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3792) |
- ASN does not support this measure for applicability to dialysis patients
but notes that it is likely appropriate for non-dialysis chronic kidney
disease patients. ASN stresses that this distinction is important for
appropriate application of this metric. Even though many patients
undergoing dialysis have high blood pressure, it is not known at this time
what the target blood pressure is that results in best health outcomes. While
there is no evidence that higher blood pressure results in higher risk for
adverse events, there is consistent evidence that dialysis patients with the
lowest blood pressure have a highest risk for death. Moreover, there are many
patients such as those with diabetes and orthostatic hypotension, in which
trying to get blood pressure to < 140/90 mm Hg is very risky. For all these
reasons, we strongly believe that this measure is inappropriate for patients
undergoing maintenance dialysis. (Submitted by: American Society of Nephrology
(ASN))
- [Pre-workgroup meeting comment] agree with the addition of the
following text -Although progression of chronic cardiac conditions may be
unavoidable, they may also result from poor quality of care or inadequate care
from precursor conditions, such as poorly controlled high blood pressure which
leads to the development of CAD, MIs and HF. Appropriate care best practices
are in place (JNC8) and if followed may result in improvement incontrolling
high blood pressure. This includes for example; patients on step medication
therapy, life style modifications and assessment for identifiable causes of
HBP including sleep apnea. support -There are numerous studies showing that
the management of OSA has on the improvement of High blood pressure form 2 ñ
10 mmhg. (Punjabi et al. PLoS Medicine 2009; 6(8):e1000132) (Lavie et al.
study. Br Med J 2000; 320: 479-82) (Young et al. SLEEP 2008;31(8):1071-1078 )
The JNC8 (and prior JNC-7) has included the identification and management of
OSA as a component of the guidelines. (Submitted by: ResMed)
- [Pre-workgroup meeting comment] ASN does not support this measure
for applicability to dialysis patients but notes that it is likely appropriate
for non-dialysis chronic kidney disease patients. ASN stresses that this
distinction is important for appropriate application of this metric. Even
though many patients undergoing dialysis have high blood pressure, it is not
known at this time what the target blood pressure is that results in best
health outcomes. While there is no evidence that higher blood pressure results
in higher risk for adverse events, there is consistent evidence that dialysis
patients with the lowest blood pressure have a highest risk for death.
Moreover, there are many patients such as those with diabetes and orthostatic
hypotension, in which trying to get blood pressure to < 140/90 mm Hg is
very risky. For all these reasons, we strongly believe that this measure is
inappropriate for patients undergoing maintenance dialysis.(Submitted by:
American Society of Nephrology (ASN))
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3794) |
- Allergan Inc. (Allergan), the manufacturer of BOTOXÆ (onabotulinumtoxinA),
appreciates the opportunity to comment on Measure Under Consideration (MUC)
X3794 and the Measures Applications Partnershipís (MAP) preliminary
recommendation. BOTOXÆ is FDA-approved for eight therapeutic indications,
including for the prophylaxis of headaches in adult patients with chronic
migraine (=15 days per month with headache lasting 4 hours a day or longer).
We respectfully disagree with MAPís preliminary recommendation to not support
the inclusion of X3794. We understand that MAPís rationale for not
supporting the inclusion of this measure is that ìthis plan of care measure
does not add much to X3771 and X3772 that addresses acute and preventive
treatment.î Allergan, however, views this plan of care measure as critically
important for chronic migraine patients. For the chronic migraine
population, the implementation of a plan of care that extends beyond the
prescription of medication(s) facilitates the provision of quality care. As
Dougherty et al. recently explained: ìThe keys to caring for chronic migraine
patients include: (1) making a proper diagnosis; (2) identifying and
eliminating exacerbating factors; (3) assessing for medication overuse
(patients with chronic headache often overuse acute medications); and (4)
continued management. Communication between patient and physician about
treatment goals is important.î (See Dougherty C, Silberstein SD. Providing
care for patients with chronic migraine: diagnosis, treatment, and management.
Pain Practice 2014 [epub before print].) In light of the above, it is
critical that chronic migraine patients are not lost in the system to follow
up. As a result, a plan of care is critically important to ensure the
provision of high quality and comprehensive care to chronic migraine patients.
Allergan respectfully disagrees with MAPís preliminary recommendation to not
support the inclusion of X3794, and we urge MAP to reconsider its initial
recommendation. I hope that you have found the information and suggestions
offered in these comments helpful. If you have any questions about these
comments, please contact A.J. Joshi, Senior Director U.S. Medical Affairs,
Neurosciences and Urology, at joshi_aj@allergan.com. Thank you in advance for
your consideration of our recommendations. References Cited: 1. BotoxÆ.
Product Information. Allergan, Inc. February 2014. 2. Dougherty C, Silberstein
SD. Providing care for patients with chronic migraine: diagnosis, treatment,
and management. Pain Practice 2014 [epub before print]. (Submitted by:
Allergan)
- The AAN strongly encourages the MAP consider offering support to this
measure, a plan of care for migraine and cervicogenic headache is a vital
piece of the patient receiving the appropriate care.(Submitted by: American
Academy of Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3796) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Medicare Shared Savings Program; MUC ID: X3797)
|
- The ACS supports the MAP Clinician Workgroupís provisional recommendation
to support of this measure for the MSSP. This measure is a relevant and
meaningful measure for breast surgeons and surgical oncologists. The measure
could also be reported by rural surgeons.(Submitted by: The American College
of Surgeons)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3797)
|
- The ACS supports the MAP Clinician Workgroupís provisional recommendation
to "conditionally support" this measure for inclusion in PQRS, Physician
Compare, and VBPM. This measure is a relevant and meaningful measure for
breast surgeons and surgical oncologists. The measure could also be reported
by rural surgeons.(Submitted by: The American College of
Surgeons)
- Would addition of the measure add value to the program measure set? Yes,
but not as currently written What is the measureís potential to improve
patient outcomes? Improved screening rates, possibly reduced breast cancer
death rates. Would use of the measure create undue data collection or
reporting burden? No Is there a better measure available or does a measure
already in the program set address a particular program objective? No Though
endorsed by many medical societies, breast cancer screening remains
controversial, particularly for older adults with limited life expectancy.
AGSí second Choosing Wisely list states: ìDonít recommend screening for breast
or colorectal cancer, nor prostate cancer (with the PSA test) without
considering life expectancy and the risks of testing, overdiagnosis and
overtreatment.î To be used appropriately this measure would need to try to
address this issue.(Submitted by: American Geriatrics Society)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3798) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3800) |
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommend this measure for inclusion in CMS programs.(Submitted
by: American Academy of Neurology)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3801) |
- The AAN supports the MAP recommendation to support this measure for
inclusion in CMS programs. (Submitted by: American Academy of
Neurology)
- HNC commends the MAP for providing conditional support for measure X3801,
Nutritional Status or Growth Trajectories Monitored, for the PQRS/Physician
Compare/Physician Feedback/VBPM. We believe that this measure reflects a
growing awareness that nutritional status can have a significant impact on
patientsí health outcomes. It should encourage providers to regularly
evaluate patientsí nutritional status, thereby contributing to better health
and better health care for patients with muscular dystrophy. Malnutrition
also is associated with acute and chronic diseases and injury other than
muscular dystrophy; certain diseases, such as cancer, stroke and chronic
obstructive pulmonary disease, may cause a person to be unable to ingest or
absorb nutrients, require more energy, or become undernourished due to dietary
restrictions. In NQFís January 2014 final report entitled, ìMAP 2014
Recommendations on Measures for More Than 20 Federal Programs,î malnutrition
was identified as a measure gap and MAP members noted ìthey would like to see
a more systematic assessment of ongoing progress towards gap-filling going
forward.î Thus, we urge MAP to add malnutrition to the high-priority list of
measure gaps in the MAP 2015 Final Pre-Rulemaking Report and to identify and
support patient-centered malnutrition measure concepts to encourage providers
to share accountability and align incentives across care settings to screen
patients for malnutrition and malnutrition risk and to provide timely and
appropriate intervention when indicated. Malnourished patients experience
increased morbidity, complications and mortality; longer hospitalizations; an
increased likelihood of hospital readmissions and need for ongoing care; and
higher healthcare costs. ï Morbidity, Complications and Mortality:
Malnourished patients are more likely to experience complications, such as
pneumonia, pressure ulcers, nosocomial infections, and death. In addition,
malnutrition is a risk factor for other severe clinical events, such as falls
and worse outcomes after surgery or trauma. ï Length of Stay: Malnourished
patients, as well as patients at risk for malnutrition, have significantly
longer hospitalizations than well-nourished patients and patients not at risk
for malnutrition. Similarly, malnourished patients in sub-acute care
facilities have longer lengths of stay than patients who are nutritionally at
risk. ï Readmission, Institutionalization and Ongoing Services: Malnutrition
is a common reason for patients to be readmitted to hospitals. One recent
study found that malnourished patients with heart failure were 36 percent more
likely to be readmitted to the hospital within 30 days than nourished patients
with heart failure. Additionally, hospitalized patients at risk of
malnutrition are more likely to be discharged to another facility or require
ongoing healthcare services after being discharged from the hospital than
patients who are not at risk for malnutrition. ï Health Care Costs:
Malnutrition increases the cost of care due to the factors described above:
increased morbidity, complications and mortality, longer hospitalizations, and
more re-admissions, continued institutionalizations and ongoing health care
services. A study published in November 2014 estimates that the total annual
burden of community-based disease-related malnutrition in the United States is
$156.7 billion. The cost impact of untreated malnutrition is illustrated
below: o Costs Related to Increased Morbidity, Complications and Mortality: A
recently published study on community-based disease-related malnutrition
indicates that almost 80 percent of the economic burden is due to morbidity
associated with disease-related malnutrition, approximately 16 percent of the
burden results from mortality and the remaining burden is associated with the
direct medical costs of treating disease-related malnutrition. High-risk
malnourished patients are 2.1 times more likely to develop pressure ulcers
than well-nourished patients. One study cited the average cost for hospital
treatment of a stage IV pressure ulcer acquired in the hospital (including the
treatment of associated medical complications) to be $129,248. The average
cost of hospital treatment of a stage IV pressure ulcer acquired in the
community (including the treatment of associated medical complications) was
$124,327. o Costs Related to Hospitalizations: Hospitalized malnourished
patients, patients at risk for malnutrition and patients who experience
declines in their nutritional status while hospitalized have higher health
care costs than well-nourished patients, patients not at risk for
malnutrition, and patients who remain properly nourished during their
hospitalizations, respectively. o Costs Related to Readmissions: Clearly,
malnourished patients and patients with nutrition-related or metabolic issues
are frequently readmitted to the hospital. Studies have demonstrated that
readmissions are 24-55 percent more costly than initial admissions and account
for 25 percent of Medicare expenditures. One study found that there were
11,855,702 Medicare fee-for-service patients discharged from hospitals between
October 1, 2003 and September 30, 2004 who were at risk for rehospitalization;
19.6 percent of the patients were readmitted within 30 days, resulting in a
cost of $17.4 billion. The presence or absence of malnutrition is not always
obvious. However, screening patients for being at risk of malnutrition,
conducting additional assessments when warranted, and providing timely,
medically indicated nutritional interventions to patients identified as
malnourished or at risk of malnutrition, can mitigate the negative outcomes
and considerable costs associated with malnutrition. Timely nutritional
therapy can address the potentially negative clinical and societal impact of
malnutrition by improving patientsí functional status, quality of life and
clinical outcomes. References Alvarez-Hernandez J, Planas Vila M, Leon-Sanz
M, et al. Prevalence and costs of malnutrition in hospitalized patients; the
PREDyCESÆ Study. Nutr Hosp. 2012; 27(4): 1049-1059. Braunschweig C, Gomez S,
Sheean PM. Impact of declines in nutritional status on outcomes in adult
patients hospitalized for more than 7 days. J Am Diet Assoc.
2000;100:1316-1322. Brem H, Maggi, J, Nierman D, et al. High cost of stage IV
pressure ulcers. Am J. Surg. 2010 October; 200(4) 473-477. Callahan CM,
Wolinsky FD. Hospitalization for pneumonia among older adults. J Gerontol.
1996; 51A:M276-M282. Cangelosi MJ, Rodday AM, Saunders BS and Cohen JT.
Evaluation of the economic burden of diseases associated with poor nutrition
status. Journal of Parenteral and Enteral Nutrition. 2014; 38 (Supp. 2):
35S-41S. Chima CS, Barco K, Dewitt ML, et al. Relationship of nutritional
status to length of stay, hospital costs, and discharge status of patients
hospitalized in the medicine service. J Am Diet Assoc. 1997; 97: 975-978.
Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality,
length of hospital stay and costs evaluated through a multivariate model
analysis. Clin Nutr. 2003;22:235-239. Heersink JT, Brown, CJ, Dimaria-Ghalili
RA and Locher JL. Undernutrition in hospitalized older adults: Patterns and
correlates, outcomes, and opportunities for intervention with a focus on
processes of care. Journal of Nutrition for the Elderly. 2010; 29:4-41.
Institute of Medicine. The role of nutrition and maintaining health in the
nationís elderly: evaluating coverage of nutrition services for the Medicare
population, 2000.
http://books.nap.edu/openbook.php?record_id=9741&page=R1. Accessed
February 24, 2010. Jencks SF, Williams MV and Coleman EA. Rehospitalizations
among patients in the Medicare fee-for-service program. N Engl J Med. 2009;
360: 1418 ñ 1428. Kassin MT, Owen RM, Perez S, et. al. Risk factors for 30-day
hospital readmission among general surgery patients. J Am Coll Surg. Sept
2012; 215(3): 322-330. Marik PE and Flemmer M. Immunonutrition in the surgical
patient. Minerva Anestesiologica. 2012; 78: 336-342. Mechanick JI. Practical
aspects of nutritional support for wound-healing patients. Am J Surg.
2004;188:52S-56S. Meijers JMM, Halfens RJG, Neyens JCL, Luiking YC, Verlaan G
and Schols JMGA. Predicting falls in elderly receiving home care: the role of
malnutrition and impaired mobility. The Journal of Nutrition and Aging; 2012;
16: 654-658. National Alliance for Infusion Therapy and the American Society
for Parenteral and Enteral Nutrition Public Policy Committee and Board of
Directors. Disease-Related Malnutrition and Enteral Nutrition Therapy: A
Significant Problem with a Cost-Effective Solution. Nutrition in Clinical
Practice. 2010; 25(5): 548-55. National Quality Forum, MAP 2014
Recommendations on Measures for More Than 20 Federal Programs: Final Report,
January 2014, available at
http://www.qualityforum.org/Publications/2014/01/MAP_Pre-Rulemaking_Report__2014_Recommendations_on_Measures_for_More_than_20_Federal_Programs.aspx.
Pichard C, Kyle UG, Morabia A, et al. Lean body mass depletion at hospital
admission is associated with an increased length of stay. Am J Clin Nutr.
2004; 79: 613-618. Schneider SM, Veyres P, Pivot X, et al. Malnutrition is an
independent factor associated with nosocomial infections. Br J Nutr. 2004;
92:105-111. Snider JT, Linthicum MT, Wu Y et. al. Economic burden of
community-based disease-associated malnutrition in the United States. Journal
of Parenteral and Enteral Nutrition. 2014; 38 (Supp. 2): 77S-85S. Somanchi M,
Tao X and Mullin GE. The facilitated early enteral and dietary management
effectiveness trial in hospitalized patients with malnutrition. Journal of
Parenteral and Enteral Nutrition. 2011; 35(2): 209 ñ 216. Sullivan DH, Walls
RC. Protein-energy undernutrition and the risk of mortality within six years
of hospital discharge. J Am Coll Nutr. 1998;17:571-578. Thomas DR, Zdrowski
CD, Wilson MM, et al. Malnutrition in subacute care. Am J Clin Nutr. 2002; 75:
308-313. Zapatero A, Barba R, Gonzalez N, et al. Influence of obesity and
malnutrition on acute heart failure. Rev Esp Cardiol. 2012; 65(5): 421-426.
(Submitted by: Healthcare Nutrition Council)
- [Pre-workgroup meeting comment] The AAN strongly encourages the MAP
to consider recommendation of this measure for inclusion in CMS
programs.(Submitted by: American Academy of Neurology)
| (Program: Physician Quality
Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3802) |
- X3802 and X3803 were developed with the intention of implementation at a
facility level, as the measure is calculated based on rendering of imaging
exams not the ordering of them. If implemented at a physician level (PQRS)
the measure would then be attributed to the radiologist. By statute,
radiologists must perform tests for which they receive orders, although they
do provide a consultative role and can recommend different or no exams be
performed. Thus, attributing these measures to a hospital outpatient
department attributes and shares responsibility across specialists and
departments, resulting in better coordination of efficient, appropriate care.
While the ACR, as measure steward, sees the benefit to also implementing at
the physician level, doing so will put many radiology groups in difficult
positions with their ordering physicians in order to comply with the measures.
The ACR recommends that these measures be implemented in the Hospital
Outpatient Quality Reporting (HOQR) program, which would align incentives and
coordination across hospital departments and between radiologists and the
ordering physician. We request that the MAP recommendations to CMS are for
inclusion in HOQR and MSSP. Once implemented in HOQR, it is more appropriate
to implement in PQRS. Also, X3802 is titled ìAppropriate use of imaging for
knee painî ñ not follow up imaging. (Submitted by: American College of
Radiology)
- [Pre-workgroup meeting comment] Comment 1: The correct measure
title is Appropriate use of imaging for knee pain. The measure focus is not on
follow up imaging recommendations, but the use of advanced imaging prior to
xray for knee pain. Comment 2: This measure was developed for implementation
at the facility level. It is better suited for the CMS Hospital Outpatient
Quality Reporting program (HOQR) than at an individual physician level in the
PQRS program. Attribution at the facility level is more appropriate as use of
imaging is determined by both the treating/ordering physician and
radiologists. To implement it at the physician level in PQRS, measure
performance would be attributed solely to radiologists or the imaging
physician. The measure was submitted to CMS under the PQRS call for measures
since there is no similar call for measures for the HOQR program. (Submitted
by: American College of Radiology)
| (Program: Medicare Shared
Savings Program; MUC ID: X3803) |
- X3802 and X3803 were developed with the intention of implementation at a
facility level, as the measure is calculated based on rendering of imaging
exams not the ordering of them. If implemented at a physician level (PQRS)
the measure would then be attributed to the radiologist. By statute,
radiologists must perform tests for which they receive orders, although they
do provide a consultative role and can recommend different or no exams be
performed. Thus, attributing these measures to a hospital outpatient
department attributes and shares responsibility across specialists and
departments, resulting in better coordination of efficient, appropriate care.
While the ACR, as measure steward, sees the benefit to also implementing at
the physician level, doing so will put many radiology groups in difficult
positions with their ordering physicians in order to comply with the measures.
The ACR recommends that these measures be implemented in the Hospital
Outpatient Quality Reporting (HOQR) program, which would align incentives and
coordination across hospital departments and between radiologists and the
ordering physician. We request that the MAP recommendations to CMS are for
inclusion in HOQR and MSSP. Once implemented in HOQR, it is more appropriate
to implement in PQRS. (Submitted by: American College of
Radiology)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3803) |
- [Pre-workgroup meeting comment] This measure was developed for
implementation at the facility level. It is better suited for the CMS Hospital
Outpatient Quality Reporting program (HOQR) than at an individual physician
level in the PQRS program. Attribution at the facility level is more
appropriate as use of imaging is determined by both the treating/ordering
physician and radiologists. To implement it at the physician level in PQRS,
measure performance would be attributed solely to radiologists or the imaging
physician. The measure was submitted to CMS under the PQRS call for measures
since there is no similar call for measures for the HOQR program. (Submitted
by: American College of Radiology)
| (Program:
Medicare Shared Savings Program; MUC ID: X3806) |
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. ASA requests additional clarity and suggestions from the MAP on
opportunities for the development of an outcome measure for PONV. While ASA
would also prefer an outcome measure, there are difficulties in designing a
measure of anesthesia care based on the incidence of PONV. Risk factors for
PONV cross three categories: patient characteristics, anesthesia risk factors,
and surgical risk factors. A PONV outcome measure that assesses PONV incidence
but does not appropriately adjust for these risk factors for each patient
encounter will combine the PONV incidence for low-risk encounters with that of
high-risk encounters, and the results will not be meaningful. To reduce the
variability from surgical risk factors, it might be reasonable to consider a
PONV measure for specific operations, but even then important patient risk
factors would greatly influence the outcomes. Reporting PONV incidence without
adjusting for these would be misleading, and selecting a certain type of
surgery or specific operation may make it difficult for many anesthesiologists
to have enough reportable cases for the measure to be of value.(Submitted by:
American Society of Anesthesiologists)
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] Postoperative nausea and vomiting
(PONV) is a significant source of patient suffering and in some cases, leads
to serious morbidity, such as dehydration, aspiration of gastric contents,
suture dehiscence, esophageal rupture, and bleeding. According to a prominent
study, patients ranked vomiting as the most undesirable outcome after surgery.
PONV frequently delays discharge after surgery, and it is the leading cause of
unplanned postoperative hospital admission. The resulting cost of PONV in the
United States has been estimated at several hundred million dollars annually.
Prophylactic therapy for PONV reduces its incidence and the associated
discomfort and costs. This is a patient-centered measure that has the
potential to both improve the quality of the patient experience as well as
prevent potentially severe clinical complications. Given the mandatory
documentation of medication administration in the perioperative period, this
measure should not create an undue burden on data collectors. Similar
measures within PQRS do not exist. (Submitted by: American Society of
Anesthesiologists)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3806) |
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. ASA requests additional clarity and suggestions from the MAP on
opportunities for the development of an outcome measure for PONV. While ASA
would also prefer an outcome measure, there are difficulties in designing a
measure of anesthesia care based on the incidence of PONV. Risk factors for
PONV cross three categories: patient characteristics, anesthesia risk factors,
and surgical risk factors. A PONV outcome measure that assesses PONV incidence
but does not appropriately adjust for these risk factors for each patient
encounter will combine the PONV incidence for low-risk encounters with that of
high-risk encounters, and the results will not be meaningful. To reduce the
variability from surgical risk factors, it might be reasonable to consider a
PONV measure for specific operations, but even then important patient risk
factors would greatly influence the outcomes. Reporting PONV incidence without
adjusting for these would be misleading, and selecting a certain type of
surgery or specific operation may make it difficult for many anesthesiologists
to have enough reportable cases for the measure to be of value.(Submitted by:
American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] Postoperative nausea and vomiting
(PONV) is a significant source of patient suffering and in some cases, leads
to serious morbidity, such as dehydration, aspiration of gastric contents,
suture dehiscence, esophageal rupture, and bleeding. According to a prominent
study, patients ranked vomiting as the most undesirable outcome after surgery.
PONV frequently delays discharge after surgery, and it is the leading cause of
unplanned postoperative hospital admission. The resulting cost of PONV in the
United States has been estimated at several hundred million dollars annually.
Prophylactic therapy for PONV reduces its incidence and the associated
discomfort and costs. This is a patient-centered measure that has the
potential to both improve the quality of the patient experience as well as
prevent potentially severe clinical complications. Given the mandatory
documentation of medication administration in the perioperative period, this
measure should not create an undue burden on data collectors. Similar
measures within PQRS do not exist. (Submitted by: American Society of
Anesthesiologists)
| (Program: Medicare
Shared Savings Program; MUC ID: X3807) |
- A barrier to national implementation would be standardizing this protocol
ñ much is dependent upon resources available at the local level.(Submitted by:
American Academy of Pediatrics)
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] Perioperative care is a complex,
multidisciplinary process involving several care teams working together.
Clinical outcomes following surgery are influenced by many factors. 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 the medical care of ICU
patients after procedures. Protocols for referral have been well established
by CMS; the use of a checklist or protocol that describe the details of an
acute episode of care to members of the care team in the post-operative
setting adds an important feature to providing patient-centered care.
Moreover, documentation of adherence (or lack thereof) to such protocols is
simple to document and should place minimal or no burden on ICU staff. CMS,
the National Quality Forum (NQF) and the World Health Organization have
recognized that transfer-of-care protocols are important to patient outcomes.
In 2010, the NQF stated, ìIncomplete or inaccurate transfer of information,
poor communication, and a lack of appropriate follow-up care can lead to
confusion and poor outcomes, such as medication errors and preventable
hospital readmissions and emergency department visits.î Similar measures
within PQRS do not exist. (Submitted by: American Society of
Anesthesiologists)
| (Program: Physician
Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback;
Value-Based Payment Modifier; MUC ID: X3807) |
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. The comments on the transfer of care measures were thoughtful and
encouraging as we work to improve care coordination across teams and settings.
While anesthesiologists initiate the pass-off and checklist in both of these
circumstances, we will consider the MAPís suggestion to transition this to a
facility-based metric. But at the same time, where physicians are independent
practitioners, the potency of a physician-level measure can reasonably be
expected to be greater than a facility measure. The diligent use of a transfer
of care protocol depends upon the uptake of an anesthesiologistís practice. We
recognize the importance of validating this measure to ensure that the
implementation of the checklist leads to its assumed results as the individual
communication styles and abilities of practitioners will likely vary. Patient
care is compromised by poor communication between medical professionals. CMS,
the National Quality Forum (NQF) and the World Health Organization have
recognized that transfer-of-care protocols are important to patient outcomes.
In addition, a recent 2014 article in the New England Journal of Medicine that
reviewed 10,740 patient admissions concluded, ìImplementation of the handoff
program was associated with reductions in medical errors and in preventable
adverse events and with improvements in communication, without a negative
effect on workflow.î Starmer AJ, Spector ND, Srivastava R, West DC,
Rosenbluth G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR,
Rothschild JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O'Toole JK, Solan LG,
Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart
JL, Patel SJ, Bale JF Jr, Spackman JB, Stevenson AT, Calaman S, Cole FS,
Balmer DF, Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP; I-PASS
Study Group: Changes in medical errors after implementation of a handoff
program. NEJM 2014; 371(19):1803-12(Submitted by: American Society of
Anesthesiologists)
- [Pre-workgroup meeting comment] Perioperative care is a complex,
multidisciplinary process involving several care teams working together.
Clinical outcomes following surgery are influenced by many factors. 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 the medical care of ICU
patients after procedures. Protocols for referral have been well established
by CMS; the use of a checklist or protocol that describe the details of an
acute episode of care to members of the care team in the post-operative
setting adds an important feature to providing patient-centered care.
Moreover, documentation of adherence (or lack thereof) to such protocols is
simple to document and should place minimal or no burden on ICU staff. CMS,
the National Quality Forum (NQF) and the World Health Organization have
recognized that transfer-of-care protocols are important to patient outcomes.
In 2010, the NQF stated, ìIncomplete or inaccurate transfer of information,
poor communication, and a lack of appropriate follow-up care can lead to
confusion and poor outcomes, such as medication errors and preventable
hospital readmissions and emergency department visits.î Similar measures
within PQRS do not exist. (Submitted by: American Society of
Anesthesiologists)
| (Program:
Medicare Shared Savings Program; MUC ID: X3808) |
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society Anesthesiologists)
- [Pre-workgroup meeting comment] 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 careful
management of antiplatelet therapy for patients with coronary stents
undergoing surgery and anesthesia, balancing surgical concerns about increased
risk of bleeding with the risk of cardiac morbidity and mortality. Patients
on an aspirin regimen commonly have their aspirin discontinued prior to
surgery due to a perceived increased risk of bleeding complications. However,
evidence shows that perioperative aspirin does not increase the risk of
bleeding and can actually decrease the risk of some complications. AHA ACC
guidelines suggest that in certain surgical patients, aspirin therapy should
be continued. PQRS measures do not capture the features of this measure. Some
measures relate to the use of aspirin or proscribing aspirin for patients with
diagnosis such as coronary artery disease (PQRS #6) or Ischemic Vascular
Disease (IVD): Use of Aspirin or Another Antithrombotic (PQRS #204).
(Submitted by: American Society of Anesthesiologists)
| (Program:
Physician Quality Reporting System (PQRS) ; Physician Compare; Physician
Feedback; Value-Based Payment Modifier; MUC ID: X3808) |
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. There is significant evidence to suggest that the antiplatelet
effects of aspirin continuation have the potential to significantly improve
cardiac outcomes for patients with drug-eluting stents, but there remains a
predictable and intuitive reticence among many practitioners to administer
aspirin preoperatively. While this is a process measure, we appreciate your
recognition that expanding the implementation of this evidence-based practice
could be enhanced by its inclusion as a PQRS measure. As the population of
patients with these coronary stents is growing rapidly, the importance of
promoting optimal care when they undergo surgery grows correspondingly more
critical.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] 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 careful
management of antiplatelet therapy for patients with coronary stents
undergoing surgery and anesthesia, balancing surgical concerns about increased
risk of bleeding with the risk of cardiac morbidity and mortality. Patients
on an aspirin regimen commonly have their aspirin discontinued prior to
surgery due to a perceived increased risk of bleeding complications. However,
evidence shows that perioperative aspirin does not increase the risk of
bleeding and can actually decrease the risk of some complications. AHA/ACC
guidelines suggest that in certain surgical patients, aspirin therapy should
be continued. PQRS measures do not capture the features of this measure. Some
measures relate to the use of aspirin or proscribing aspirin for patients with
diagnosis such as coronary artery disease (PQRS #6) or Ischemic Vascular
Disease (IVD): Use of Aspirin or Another Antithrombotic (PQRS #204).
(Submitted by: American Society of Anesthesiologists)
| (Program: Medicare Shared Savings Program; MUC ID:
X3809) |
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] The measure will add value to the
program measure set as it focuses on patient outcomes rather than the process
of care. Unintended perioperative hypothermia occurs in up to 20% of surgical
patients. 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. Postoperative
shivering is a significant complaint among surgical patients. The desired
outcome, reduction in adverse surgical effects due to perioperative
hypothermia and a more satisfactory patient experience, is affected by
maintenance of normothermia during surgery. Medical literature also supports a
temperature of >35.5 degrees Centigrade as being associated with improved
outcomes. The currently endorsed measure (PQRS #193) for Perioperative
Temperature Management related to anesthesia care includes both outcome
(achieving a first temperature of 36 degrees centigrade) and process (use of
forced-air warming) in order to achieve compliance. In recent years, ASA and
the AMA-PCPI workgroup have expressed concerns regarding the growth in new
technologies for intraoperative warming and the absence of evidence of
efficacy of some of these technologies. Because a significant component of the
original measure would have been changed, ASA believes this measure will have
a greater impact on measuring the quality of care a patient receives than PQRS
#193. (Submitted by: American Society of Anesthesiologists)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3809) |
- Often, within a short window of time, a single absolute measurement has
little value. A change in temperature (i.e., towards hypothermia) is what is
important.(Submitted by: American Academy of Pediatrics)
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. The ASA submitted this outcome measure for inclusion in PQRS 2016
and is preparing to submit this measure as a new measure for NQF endorsement
in January 2015. In May 2014, the ASA submitted the specifications for this
outcome measure as part of the maintenance process for NQF #0454/PQRS #193.
ASA then withdrew the measure as a result of recommendations from the Surgery
Standing Committee that this measure (outcome) was substantively different
from the currently-used NQF #0454/PQRS #193 (process measure). The measure as
submitted reflects the direction of CMS and the NQF in encouraging
ìhigh-valueî outcome measures over process measures. The outcome measure under
consideration targets a similar population as NQF #0454/PQRS #193 and has a
similar intent as the currently-used PQRS #193 process measure ñ a measure
that has been in use in PQRS for several years. Recent scientific evidence
has noted deficiencies in the process measure as originally specified
(Steelman VN, Perkhounkova YS, Lemke JH. The gap between compliance with the
quality performance measure ìPerioperative Temperature Managementî and
normothermia. Journal for Healthcare Quality 2014.) This paper observed that
5.8% of patients who ìpassedî the measure were still hypothermic in the
Postanesthesia Care Unit, and thus at risk for adverse outcomes. Since May
2014, ASA has conducted further testing on this measure under consideration
and argues that this measure constitutes a better level of quality than the
currently endorsed and used PQRS #193. As stated in our previous comments, a
drop in core temperature during surgery, known as perioperative hypothermia,
can result in numerous adverse effects, which can include adverse myocardial
ischemia, infarction or dysrhythmia, 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 strongly influenced by intraoperative anesthesia practice and
the attention paid to preserving and supporting core body temperature during
the case. (Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] The measure will add value to the
program measure set as it focuses on patient outcomes rather than the process
of care. Unintended perioperative hypothermia occurs in up to 20% of surgical
patients. 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. Postoperative
shivering is a significant complaint among surgical patients. The desired
outcome, reduction in adverse surgical effects due to perioperative
hypothermia and a more satisfactory patient experience, is affected by
maintenance of normothermia during surgery. Medical literature also supports a
temperature of >35.5 degrees Centigrade as being associated with improved
outcomes. The currently endorsed measure (PQRS #193) for Perioperative
Temperature Management related to anesthesia care includes both outcome
(achieving a first temperature of 36 degrees centigrade) and process (use of
forced-air warming) in order to achieve compliance. In recent years, ASA and
the AMA-PCPI workgroup have expressed concerns regarding the growth in new
technologies for intraoperative warming and the absence of evidence of
efficacy of some of these technologies. Because a significant component of the
original measure would have been changed, ASA believes this measure will have
a greater impact on measuring the quality of care a patient receives than PQRS
#193. (Submitted by: American Society of Anesthesiologists)
| (Program: Medicare Shared Savings Program; MUC ID: X3810)
|
- This may have more value at the local/system level, rather than as a
national level measure.(Submitted by: American Academy of
Pediatrics)
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] Perioperative care is a complex,
multidisciplinary process involving several care teams working together.
Clinical outcomes following surgery are influenced by many factors.
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. One important venue for such
miscommunication is the handoff that occurs when a patient is transferred from
one team of practitioners to another, such as in the peri-procedure setting.
The peri-procedure setting is unique in that it often requires communication
between different practitioner types with different backgrounds, the transfer
of multiple types of information (surgical, medical and anesthetic), and, the
transfer of technology (e.g. monitor). Because these peri-procedure
transitions of care are vulnerable to poor communication and a failure to
share important clinical details, the focus of this measure is to improve the
post-anesthetic handoff for all patients who undergo an anesthetic under the
direction of an anesthesia practitioner and are admitted to a PACU. Protocols
for referral have been well established by CMS; the use of a checklist or
protocol that describe the details of an acute episode of care and the care a
patient received within the operating room to members of the care team in the
post-operative setting adds an important feature to providing patient-centered
care. Similar to transferring care in an ICU, documentation of adherence (or
lack thereof) to such protocols is simple to document and should place minimal
or no burden on PACU staff. CMS, the National Quality Forum (NQF) and the
World Health Organization have recognized that transfer-of-care protocols are
important to patient outcomes. In 2010, the NQF stated, ìIncomplete or
inaccurate transfer of information, poor communication, and a lack of
appropriate follow-up care can lead to confusion and poor outcomes, such as
medication errors and preventable hospital readmissions and emergency
department visits.î Similar measures within PQRS do not exist. (Submitted by:
American Society of Anesthesiologists)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3810)
|
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. The comments on the transfer of care measures were thoughtful and
encouraging as we work to improve care coordination across teams and settings.
While anesthesiologists initiate the pass-off and checklist in both of these
circumstances, we will consider the MAPís suggestion to transition this to a
facility-based metric. But at the same time, where physicians are independent
practitioners, the potency of a physician-level measure can reasonably be
expected to be greater than a facility measure. The diligent use of a transfer
of care protocol depends upon the uptake of an anesthesiologistís practice. We
recognize the importance of validating this measure to ensure that the
implementation of the checklist leads to its assumed results as the individual
communication styles and abilities of practitioners will likely vary. Patient
care is compromised by poor communication between medical professionals. CMS,
the National Quality Forum (NQF) and the World Health Organization have
recognized that transfer-of-care protocols are important to patient outcomes.
In addition, a recent 2014 article in the New England Journal of Medicine that
reviewed 10,740 patient admissions concluded, ìImplementation of the handoff
program was associated with reductions in medical errors and in preventable
adverse events and with improvements in communication, without a negative
effect on workflow. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth
G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild
JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O'Toole JK, Solan LG, Aylor M,
Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart JL, Patel
SJ, Bale JF Jr, Spackman JB, Stevenson AT, Calaman S, Cole FS, Balmer DF,
Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP; I-PASS Study Group:
Changes in medical errors after implementation of a handoff program. NEJM
2014; 371(19):1803-12 (Submitted by: American Society of
Anesthesiologists)
- [Pre-workgroup meeting comment] Perioperative care is a complex,
multidisciplinary process involving several care teams working together.
Clinical outcomes following surgery are influenced by many factors.
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. One important venue for such
miscommunication is the handoff that occurs when a patient is transferred from
one team of practitioners to another, such as in the peri-procedure setting.
The peri-procedure setting is unique in that it often requires communication
between different practitioner types with different backgrounds, the transfer
of multiple types of information (surgical, medical and anesthetic), and, the
transfer of technology (e.g. monitor). Because these peri-procedure
transitions of care are vulnerable to poor communication and a failure to
share important clinical details, the focus of this measure is to improve the
post-anesthetic handoff for all patients who undergo an anesthetic under the
direction of an anesthesia practitioner and are admitted to a PACU. Protocols
for referral have been well established by CMS; the use of a checklist or
protocol that describe the details of an acute episode of care and the care a
patient received within the operating room to members of the care team in the
post-operative setting adds an important feature to providing patient-centered
care. Similar to transferring care in an ICU, documentation of adherence (or
lack thereof) to such protocols is simple to document and should place minimal
or no burden on PACU staff. CMS, the National Quality Forum (NQF) and the
World Health Organization have recognized that transfer-of-care protocols are
important to patient outcomes. In 2010, the NQF stated, ìIncomplete or
inaccurate transfer of information, poor communication, and a lack of
appropriate follow-up care can lead to confusion and poor outcomes, such as
medication errors and preventable hospital readmissions and emergency
department visits.î Similar measures within PQRS do not exist. (Submitted by:
American Society of Anesthesiologists)
| (Program: Medicare Shared Savings Program; MUC ID:
X3811) |
- ASA thanks the MAP for their consideration of this measure for the
Medicare Shared Savings Program (MSSP). ASA again echoes MAP recommendations
that the MSSP Measure Set be enhanced with the addition of acute and
post-acute care measures. Existing MSSP composite measures pertain only to
primary care and long-term management of medical conditions. We would welcome
a composite measure that would pertain to anesthesia care or the quality of
perioperative care (including anesthesiologist-provided care), but thus far,
no such measure exists. We ask for further clarity and direction from the
MAP.(Submitted by: American Society of Anesthesiologists)
- [Pre-workgroup meeting comment] I am a staff anesthesiologist
practicing at Mayo Clinic in Rochester, MN. Our group has used the smoking
abstinence measure for the past several years as a research tool and as a
quality improvement instrument. This measure aligns with our institutional
and professional priorities: to improve patient health by taking advantage of
surgical procedures as a ìteachable momentî to effect behavioral change
related to smoking cessation. As a shared-accountability measure, the smoking
abstinence measure allows anesthesiologists to team with surgeons to design
optimal patient-centered interventions to maximize patient success in quitting
smoking. (Submitted by: David Martin, MD, PhD)
- [Pre-workgroup meeting comment] This measure could potentially
improve surgical outcomes for numerous patients and provide an access point
for smoking cessation that we know from previous research can be particularly
effective in helping patient's quit. This measure is easy to implement and has
the potential for major improvements in patient health.(Submitted by: Mayo
Clinic)
- [Pre-workgroup meeting comment] Anesthesia Smoking Abstinence
measure fills a critical gap in care; that pre-surgery smoking cessation
interventions are key to improving patient outcomes on the day of surgery and
may have lasting impact on a smokerís chances of quitting for good. This
team-based measure requires the clinician who schedules the patient for a
procedure (e.g., surgeon) or who provides preoperative medical evaluation
(e.g., anesthesiologist, primary care physician) to provide counseling to the
patient before surgery. The clinician emphasizes the importance of abstaining
from smoking during the day of the procedure. On the day of the procedure, the
anesthesiologist measures either the exhaled carbon monoxide level prior to
the procedures (lower levels indicate abstinence from smoking) or
self-reported abstinence from smoking as a means to determine whether the
patient succeeded in maintaining abstinence. The measure can be paired with
other measures used to track patient outcomes and smoking cessation thirty
days after the procedure. Research has documented that the time of surgery is
an especially ìteachable momentî and offers an even greater chance for
impacting long-term patient behavior. Patients need to know that perioperative
abstinence from smoking reduces complications. Short-term abstinence (at least
12 hours) nearly eliminates nicotine from the body and reduces carbon monoxide
levels to near normal. The duration of abstinence needed for benefit is not
known, but there is evidence of benefit even if a patient stops smoking after
surgery. For example, the incidence of intraoperative ST depression (often
indicating cardiac ischemia) is less in patients that have acutely stopped
smoking. In 2010 a system was established in the clinical practice of two
hospitals (Mayo Clinic Rochester) to record both of the reporting options for
this measure: exhaled carbon monoxide levels and self-reported abstinence,
both measured the morning of surgery. The results are entered into the
electronic health record by the preoperative nurses. This system has been well
integrated into the clinical practice, with over 2,500 cigarette smokers
identified annually. Overall, 44% of these smokers self-report abstinence the
morning of surgery, which agrees well with 47% of smokers who have carbon
monoxide levels consistent with abstinence. For patients evaluated in the
Preoperative Clinic, which evaluates approximately 15% of these patients prior
to surgery and which recommends abstinence from tobacco, 63% self-report
abstinence, showing that preoperative advice to quit can be effective. In an
experimental study implementing a brief clinician-delivered intervention
specifically to encourage abstinence the morning of surgery, 77% of patients
self-reported abstinence from cigarettes. This experience demonstrates that 1)
it is feasible to measure the patient outcomes of this measure in a busy
clinical practice, and 2) that interventions delivered by clinicians
evaluating smokers prior to procedures can be efficacious. Thus, this measure
has the potential to significantly improve perioperative outcomes in surgical
patients who smoke ñ in addition to the tremendous health benefits that will
accrue if smokers can maintain prolonged abstinence after surgery. PQRS 2015
includes two tobacco use measures ñ PQRS #226 (Screening and Cessation
Intervention) and PQRS #402 (Quitting Among Adolescents) several
tobacco-related measures. The established measures are aimed primarily at
primary care ñ this measure looks at surgical patients. (Submitted by:
American Society of Anesthesiologists)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3811) |
- ASA appreciates the work of the MAP Clinician Workgroup and their
encouragement that the measure undergo continued development. ASA requests the
MAP reconsider their recommendation and support this measureís inclusion in
PQRS 2016. As previous stated by ASA, the measure is currently in the clinical
practice of one hospital with multiple campuses (Mayo Clinic Rochester).
Preliminary evidence demonstrates that the team-based measure has had an
impact on individual patients and patient health. This large, multi-site
healthcare system treats a diverse patient population and encompasses
innovative and comprehensive practice styles. Increasing the penetration of
enterprise-wide electronic healthcare records into perioperative documentation
will facilitate recording and reporting of smoking cessation counseling across
multiple sites, including within the anesthesia practice and in the National
Anesthesia Clinical Outcomes Registry.(Submitted by: American Society of
Anesthesiologists)
- [Pre-workgroup meeting comment] I am a staff anesthesiologist
practicing at Mayo Clinic in Rochester, MN. Our group has used the smoking
abstinence measure for the past several years as a research tool and as a
quality improvement instrument. This measure aligns with our institutional
and professional priorities: to improve patient health by taking advantage of
surgical procedures as a ìteachable momentî to effect behavioral change
related to smoking cessation. As a shared-accountability measure, the smoking
abstinence measure allows anesthesiologists to team with surgeons to design
optimal patient-centered interventions to maximize patient success in quitting
smoking. (Submitted by: David Martin, MD, PhD)
- [Pre-workgroup meeting comment] I am an anesthesiologist at Mayo
Clinic, Rochester, MN. We have utilized this measure for several years as a
means to improve tobacco interventions delivered to our surgical patients and
help them quit smoking, which has long-term benefits to their health and
short-term benefit to decrease their risk of perioperative complications. The
measure is quite feasible to apply in our practice, with minimal
implementation burden. Most of our patients want to quit smoking, and
appreciate our efforts on their behalf to help them do so. The specificity of
the measure to our surgical practice is quite helpful, as this is a unique
opportunity to help smokers quit.(Submitted by: David O. Warner,
M.D.)
- [Pre-workgroup meeting comment] Perioperative tobacco cessation
interventions can reduce perioperative morbidity and may improve long-term
smoking cessation. This measure should be adopted to improve public health
and to incentive smoking cessation interventions by surgeons and
anesthesiologists around the time of surgery.(Submitted by: University of
Minnesota Health)
- [Pre-workgroup meeting comment] Anesthesia Smoking Abstinence
measure fills a critical gap in care; that pre-surgery smoking cessation
interventions are key to improving patient outcomes on the day of surgery and
may have lasting impact on a smokerís chances of quitting for good. This
team-based measure requires the clinician who schedules the patient for a
procedure (e.g., surgeon) or who provides preoperative medical evaluation
(e.g., anesthesiologist, primary care physician) to provide counseling to the
patient before surgery. The clinician emphasizes the importance of abstaining
from smoking during the day of the procedure. On the day of the procedure, the
anesthesiologist measures either the exhaled carbon monoxide level prior to
the procedures (lower levels indicate abstinence from smoking) or
self-reported abstinence from smoking as a means to determine whether the
patient succeeded in maintaining abstinence. The measure can be paired with
other measures used to track patient outcomes and smoking cessation thirty
days after the procedure. Research has documented that the time of surgery is
an especially ìteachable momentî and offers an even greater chance for
impacting long-term patient behavior. Patients need to know that perioperative
abstinence from smoking reduces complications. Short-term abstinence (at least
12 hours) nearly eliminates nicotine from the body and reduces carbon monoxide
levels to near normal. The duration of abstinence needed for benefit is not
known, but there is evidence of benefit even if a patient stops smoking after
surgery. For example, the incidence of intraoperative ST depression (often
indicating cardiac ischemia) is less in patients that have acutely stopped
smoking. In 2010 a system was established in the clinical practice of two
hospitals (Mayo Clinic Rochester) to record both of the reporting options for
this measure: exhaled carbon monoxide levels and self-reported abstinence,
both measured the morning of surgery. The results are entered into the
electronic health record by the preoperative nurses. This system has been well
integrated into the clinical practice, with over 2,500 cigarette smokers
identified annually. Overall, 44% of these smokers self-report abstinence the
morning of surgery, which agrees well with 47% of smokers who have carbon
monoxide levels consistent with abstinence. For patients evaluated in the
Preoperative Clinic, which evaluates approximately 15% of these patients prior
to surgery and which recommends abstinence from tobacco, 63% self-report
abstinence, showing that preoperative advice to quit can be effective. In an
experimental study implementing a brief clinician-delivered intervention
specifically to encourage abstinence the morning of surgery, 77% of patients
self-reported abstinence from cigarettes. This experience demonstrates that 1)
it is feasible to measure the patient outcomes of this measure in a busy
clinical practice, and 2) that interventions delivered by clinicians
evaluating smokers prior to procedures can be efficacious. Thus, this measure
has the potential to significantly improve perioperative outcomes in surgical
patients who smoke ñ in addition to the tremendous health benefits that will
accrue if smokers can maintain prolonged abstinence after surgery. PQRS 2015
includes two tobacco use measures ñ PQRS #226 (Screening and Cessation
Intervention) and PQRS #402 (Quitting Among Adolescents) several
tobacco-related measures. The established measures are aimed primarily at
primary care ñ this measure looks at surgical patients. (Submitted by:
American Society of Anesthesiologists)
| (Program: Medicare Shared Savings Program; MUC ID: X3813)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Physician Quality Reporting System (PQRS) ; Physician
Compare; Physician Feedback; Value-Based Payment Modifier; MUC ID: X3813)
|
- AUGS disagrees with the MAP recommendation that these measures should only
be included in the PQRS, VBM program once they have been approved by the NQF.
Unfortunately, due to the short amount of time between the call for measures
and the deadline for surgery measures, AUGS was unable to submit all of the
measures that it had submitted to PQRS for 2016. However, given the lack of
measures for reporting regarding care for patients with pelvic floor
disorders, including prolapse, we believe the MAP recommendation should
instead be to support the measures for inclusion in PQRS, VBM and that is be
encouraged for these measures to be submitted to the NQF for endorsement.
These measures should be not be held up based on whether the NQF will have
resources to put out multiple calls for surgical measures in 2015.
Furthermore, these are new measures and AUGS believes they would first be
placed into the PQRS, VBM program as individual measures and then in
subsequent years, once they have been used and data has been collected be
considered for inclusion as a composite measure.(Submitted by: American
Urogynecologic Society)
| (Program: Medicare Shared Savings Program; MUC ID:
X3816) |
- [Pre-workgroup meeting comment] Yes, under certain conditions - The
issue of reinfection should be addressed. How long after infection resolves
should follow up continue? The idea of measuring SVR post therapy and the next
12 to 24 months out should be part of the measure. (Submitted by: Academy of
Managed Care Pharmacy)
| (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: X3816) |
- Also agree with pairing.(Submitted by: Armstrong Instititue for Patient
Safety and Quality)
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] Yes, under certain conditions - The
issue of reinfection should be addressed. How long after infection resolves
should follow up continue? The idea of measuring SVR post therapy and the next
12 to 24 months out should be part of the measure. (Submitted by: Academy of
Managed Care Pharmacy)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3816) |
- [Pre-workgroup meeting comment] We are in support of use of this
measure despite not having been reviewed or endorsed by NQF, as it fills
important gaps in measurement. We would appreciate the inclusion of more
infectious diseases related measures into federal reporting programs to help
improve the quality of care of patients with infectious diseases and to ensure
that infectious diseases specialists have more relevant measures to choose
from when attempting to satisfy reporting requirements across federal
programs.(Submitted by: The Infectious Diseases Society of
America)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment. We would like to share a minor correction to the listing of this
measure. The steward is listed as the American Medical Association. We would
prefer the listing to reference the American Medical Association-convened
Physician Consortium for Performance Improvement (AMA-PCPI), consistent with
other AMA-PCPI stewarded measures on the list. (Submitted by: American
Medical Association-convened Physician Consortium for Performance Improvement
)
- [Pre-workgroup meeting comment] Yes, under certain conditions - The
issue of reinfection should be addressed. How long after infection resolves
should follow up continue? The idea of measuring SVR post therapy and the next
12 to 24 months out should be part of the measure. (Submitted by: Academy of
Managed Care Pharmacy)
- [Pre-workgroup meeting comment] ASN suggests that regulations and
metrics remain aligned and, given current regulations, notes a discrepancy
between these proposed measures (X3512 and X3816) and the current Conditions
for Coverage, which, in 2008, specified an exemption for hepatitis C
screening, since Medicare only covers diagnostic hepatitis C testing when
indicated and does not cover general screening for hepatitis C. The CDC
recommends assessing Hepatitis C serologies in order to detect an outbreak of
Hepatitis C, not in order to treat Hepatitis C. If the intent of these
proposed measures is to encourage treatment of Hepatitis C, as they seem to
be, ASN suggests that this metric may be premature, pending further research
into the efficacy, safety and utility of treatment of Hepatitis C in dialysis
patients, particularly in those patients unlikely to receive kidney
transplants and those without other evidence of liver disease.(Submitted by:
American Society of Nephrology (ASN))
| (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: X3817) |
- The Academy agrees with NQF MAP that taking into account how children are
screened, the tool that is used, and who is doing the screening would all be
improvements for this measure. The Academy recommends using Prevent Blindness
America ñapproved screening tools, including HOTV or Lea symbols distance
visual acuity chart. Additionally, we encourage that the ìwhoî remains open to
schools, nurses, physicians, optometrists and other relevant organizations, so
as to not limit childrenís access to vision screenings. While NQF MAPís
recommendation is to encourage further development, the Academy urges the
measure developer to preserve the original intent of this measure. For
example, this measure was initially developed to monitor performance in the
medical home for vision screening, and this role should be maintained, perhaps
with the means to analyze this subgroup. Additionally, we encourage that the
measure be maintained as a vision screening measure, rather than an
examination measure, as that was not the original intent of the
measure.(Submitted by: American Academy of Ophthalmology)
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
| (Program: Physician Quality Reporting System (PQRS) ;
Physician Compare; Physician Feedback; Value-Based Payment Modifier; MUC
ID: X3817) |
- The Academy agrees with NQF MAP that taking into account how children are
screened, the tool that is used, and who is doing the screening would all be
improvements for this measure. The Academy recommends using Prevent Blindness
America ñapproved screening tools, including HOTV or Lea symbols distance
visual acuity chart. Additionally, we encourage that the ìwhoî remains open to
schools, nurses, physicians, optometrists and other relevant organizations, so
as to not limit childrenís access to vision screenings. While NQF MAPís
recommendation is to encourage further development, the Academy urges the
measure developer to preserve the original intent of this measure. For
example, this measure was initially developed to monitor performance in the
medical home for vision screening, and this role should be maintained, perhaps
with the means to analyze this subgroup. Additionally, we encourage that the
measure be maintained as a vision screening measure, rather than an
examination measure, as that was not the original intent of the
measure.(Submitted by: American Academy of Ophthalmology)
- The American Optometric Association represents 33,000 doctors of optometry
and optometry students. Optometrists serve patients in nearly 6,500
communities across the country, and in 3,500 of those communities optometrists
are the only eye doctors available. As noted in the AOAís December 5 comments
on the measures under consideration list, the AOA has serious concerns with
the ìAmblyopia Screening in Childrenî quality measure developed by the Office
of the National Coordinator for Health Information Technology (ONC) and
Centers for Medicare & Medicaid Services (CMS). The MAP has indicated
that they encourage continued development of this measure and noted that the
measure needs to take into account how children are screened, the tool that is
used and who is doing the screening. The AOA strongly opposes the measure as
it currently exists and agrees that screening methods, screening
administrators and the tools used for screening are serious concerns that must
be considered. Moving forward with the measure without considering the
important issues the MAP identified would provide us with a misdirected
quality measure that does not accurately provide usable accurate data, or
improve quality. Ultimately, the AOA believes that development of this measure
should not continue, because of potential for misuse. As previously noted,
the AOA believes that it will be extremely challenging to define what a
screening is for the purpose of this measure. More importantly the screening
methodologies that currently exist are severely lacking in sensitivity which
immediately calls into question the ability to interpret any data that could
potentially be captured through the proposed measure. If this measure is
continued to be developed, the AOA believes that it will require significant
work. Additionally, if this measure is refined it should continue to focus
specifically on amblyopia and should under no circumstances be referred to
generally as a ìvision screening.î The AOA has specific recommendations for
improvements for this measure and we will share those with the measure
developers directly. Thank you for the opportunity to comment on this
measure. (Submitted by: American Optometric Association )
- [Pre-workgroup meeting comment] The American Optometric Association
(AOA) represents 33,000 doctors of optometry and optometry students. The AOA
is the voice of the nationís doctors of optometry, and a leading authority on
eye health, vision care and patient safety issues. Optometrists serve
patients in nearly 6,500 communities across the country, and in 3,500 of those
communities are the only eye doctors. Doctors of optometry provide more than
two-thirds of all primary eye and vision health care in the United States.
Optometrists also provide much of the primary eye and vision health care for
Americaís children. With that experience and expertise, we provide this
feedback on the ìAmblyopia Screening in Childrenî quality measure developed by
the Office of the National Coordinator for Health Information Technology and
Centers for Medicare & Medicaid Services. While the AOA appreciates the
accuracy of the title of the proposed measure and its focus on amblyopia, the
AOA has serious concerns with the specifics of the measure. The AOA does not
support the use of this measure in quality reporting programs and recommends
that the measure be revised to better capture needed eye care for Americaís
children. As proposed, the measure numerator is defined as ìChildren 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.î The
AOA believes that it will be extremely challenging to define what a screening
is for the purpose of this measure and more importantly the screening
methodologies that currently exist are severely lacking in sensitivity which
immediately calls into question the ability to interpret any data that could
potentially be captured through the proposed amblyopia screening measure.
While the AOA appreciates that the measure stewards recognize the serious
need for increased access to eye care for children, the proposed measure could
benefit from additional refinement. In 2011, the United States Preventive
Services Taskforce (USPSFT) assigned a ìBî grade to the recommendation for a
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. However,
there is currently a lack of harmonization and no uniform vision screening
methodology that exists. It is critical to note that when the most common
USPSTF vision screening methodologies are employed only 5.6 percent of all
preschool children are identified as warranting additional care or referral.
This is far below the actual number of children who have vision problems. The
National Eye Institute (NEI) prevalence study reveals 20.9 percent of
preschoolers have significant hyperopia,10.1 percent have significant
astigmatism, 3.8 percent have significant myopia, and 2.4 percent have
significant strabismus. Because of deficient screening methodologies, there
are alarmingly high rates of false negatives. As written, the proposed measure
would potentially rely on insufficient screening methods which would
significantly impact the accuracy of the data captured and unfortunately would
do little to meet organizational priorities to improve access to quality eye
care for children. For the first time in U.S. history, through the
Affordable Care Act (ACA), vision care for children is covered as a basic
essential benefit. Direct access to vision care for children from birth
through age 18, including; annual comprehensive eye exams and glasses, is the
new standard of basic medical coverage offered through the state insurance
exchanges, at every level. The ACA provides essential access to eye
examinations which supports a childís overall physical, mental and social
health, development and educational advancement opportunities. Building upon
the progress made in ensuring access to needed eye care through the Affordable
Care Act, the AOA recommends that an alternative measure be developed to more
accurately and effectively capture whether children are receiving necessary
eye examinations. The AOA urges the Measure Applications Partnership (MAP) to
consider whether the proposed measure is adequate and whether more could be
done to better capture essential care for children. A recommended revision is
included below for consideration. Measure Title: Eye Examination in
Children Description: The percentage of children age 3-6 who received an eye
exam by an eye doctor (optometrist or ophthalmologist) at least once by 6
years of age; and if necessary, were referred appropriately. Recommended for
the following CMS Programs: Medicare and Medicaid EHR Incentive Programs for
Eligible Professionals, Medicare Physician Quality Reporting System, Physician
Compare, Physician Feedback/Quality and Resource Utilization Reports,
Physician Value-Based Payment Modifier Measure Numerator: Children who turn 6
years of age during the measurement period and who had at least one eye
examination by an eye doctor (optometrist or ophthalmologist) during the
measurement period. Measure Denominator: Children between 3-6 years old.
(Submitted by: American Optometric Association )
| (Program: Medicare and Medicaid EHR Incentive Programs
for Eligible Professionals; MUC ID: X4007) |
- Also difficult to know the content of counseling to know if psychological
and pharmacologic was included.(Submitted by: Armstrong Instititue for Patient
Safety and Quality)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment. We would like to share a minor correction to the listing of this
measure. The current steward is the American Psychiatric Association (APA).
The AMA and APA are joint copyright holders. (Submitted by: American Medical
Association-convened Physician Consortium for Performance
Improvement)
| (Program: Medicare and Medicaid EHR Incentive
Programs for Eligible Professionals; MUC ID: X4208) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Armstrong
Instititue for Patient Safety and Quality)
- [Pre-workgroup meeting comment] Thank you for the opportunity to
comment. We would like to share a minor correction to the listing of this
measure. The current steward is the American Psychiatric Association (APA).
The AMA and APA are joint copyright holders. (Submitted by: American Medical
Association-convened Physician Consortium for Performance
Improvement)
| (Program: Hospital Outpatient Quality Reporting Program; MUC ID:
X607) |
- While written comments were not provided, the commenter indicated their
support for MAP's preliminary recommendation (Submitted by: Johns Hopkins
Hospital)
- Premier is supportive of and committed to the reduction of inappropriate
or non-evidence-based testing which is both potentially harmful to patients
and also costly to the system. We are concerned that this measure, which is
based on coded discharge data from the ED, cannot adequately account for
clinical exclusions. There is a published literature which suggests that 65%
of patients with a documented indication for CT could not be identified in
coded data. This measure needs validity testing before it can be supported.
Secondly, a set of universally accepted evidence-based guidelines for use of
CT does not exist. Thirdly and relatedly, the optimum number of such CT scans
is unknown; we are sure it is not 0 and sure it is not 100%, otherwise we have
no idea. (Submitted by: Premier, Inc.)
- [Pre-workgroup meeting comment] The AAN supports the inclusion of
this measure in CMS programs.(Submitted by: American Academy of
Neurology)
- [Pre-workgroup meeting comment] ACEP appreciates the opportunity to
comment on OP-15: Use of Brain Computed Tomography (CT) in the Emergency
Department for Atraumatic Headache. ACEP has had a series of discussions with
the measure developer regarding this measure for the past several years. ACEP
appreciates the lengths that the measure developer has gone to include more
appropriate exclusions, but many of our primary concerns remain as described
below. Of note, the National Quality Forum has never endorsed OP-15 based on a
lack of evidence. First, there is not a clinical evidence base to support
performance measurement of CT imaging in Medicare beneficiaries with headache.
ACEP is actively engaged in work to address inappropriate use of imaging. We
have established a clinical policy (guideline) addressing the issue of brain
CT imaging in headache.1 Our guideline does not include older adults or adults
on anticoagulant medications, as there is not published high-quality evidence
to support their inclusion. In fact, four clinical practice guidelines and
several studies note that new onset headaches in patients aged more than 50,
60, or 65 years are ìred flagsî that indicate that a brain CT should be
performed. Additionally, there is not a clinical decision rule or other
evidence based tool that clinicians should use to ìimproveî their performance
on OP-15. Second, ACEP does not support implementation of an administrative
measure such as OP-15 without validation by chart review. ACEP greatly
appreciates that CMS and the contracted measure developer have attempted to
incorporate the additional risk factors that we have commented on previously
into the measure exclusions, such as patients who are taking anticoagulants,
HIV positive status, a history of cancer, and other risk factors.1-9 However,
ACEP remains doubtful that the majority of evidence-based clinical indications
for head CT imaging can be adequately captured by the claims data collected by
CMS.2 Additionally, we are not convinced that the measure accurately or
reliably characterize patient complaints and comorbidities. Third, ACEP is
concerned that the implementation of OP-15 would create pressure for hospitals
and emergency clinicians to reduce the use of brain CT in this older
population who are at high-risk of having significant intracranial findings,
without any evidence as to how to do so safely or appropriately. The
recommendation of such a measure should be based on evidence that the risk of
adverse outcomes (e.g. intracranial hemorrhage or stroke within several weeks)
among patients not getting CT scans is very low, e.g. <1%. However,
preliminary data analysis does not show a model for safe practice. Use of
OP-15 would pressure hospitals and physicians to reduce use of CT without
evidence that there is currently safe practice in low imaging hospitals. No
patient, clinician or expert witness would accept a guideline or protocol for
determining head imaging in headache with an adverse event rate this high.
While ACEP and our member experts are ready willing, and able to work with
the measure developer to develop evidence-based measures of imaging efficiency
in EDs, we have not been convinced that OP-15 meets the criteria for a
high-quality performance measure. We suggest that measure developers focus on
imaging efficiency measures for which the evidence regarding appropriate use
is more robust. References 1. Edlow JA, Panagos PD, Godwin SA, Thomas TL,
Decker WW, American College of Emergency Physicians. Clinical Policy: Critical
issues in the evaluation and management of adult patients presenting to the
emergency department with acute headache. Ann Intern Med 2008; 52(4): 407-36.
2. Schuur JD, Brown MD, Cheung DS, Graff L 4th, Griffey RT, Hamedani AG,
Kelly JJ, Klauer K, Phelan M, Sierzenski PR, Raja AS. Assessment of Medicare's
Imaging Efficiency Measure for Emergency Department Patients with Atraumatic
Headache. Ann Emerg Med. 2012 Feb 23. 3. D.P. Breen, C.W. Duncan, A.E. Pope,
A.J. Grays and R. AL-Shahi Salman, Emergency department evaluation of sudden,
severe headache. Q J Med 2008; 101:435ñ443. 4. Institute for Clinical Systems
Improvement (ICSI). Diagnosis and treatment of headache. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2009 Mar. 76 p. 5. Jordan
JE, Wippold FJ II, Cornelius RS, Amin-Hanjani S, Brunberg JA, Davis PC, De La
Paz RL, Dormont D, Germano I, Gray L, Mukherji SJ, Seidenwurm DJ, Sloan MA,
Turski PA, Zimmerman RD, Zipfel GJ, Expert Panel on Neurologic Imaging. ACR
Appropriateness CriteriaÆ headache. [online publication]. Reston (VA):
American College of Radiology (ACR);2009,8p. 6. Scottish Intercollegiate
Guidelines Network (SIGN). Diagnosis and management of headache in adults. A
national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network (SIGN); 2008 Nov. 81 p 7. Locker TE, Thompson C, Rylance J,
Mason SM. The utility of clinical features in patients presenting with
nontraumatic headache: an investigation of adult patients attending an
emergency department. Headache 2006; 46(6): 954-61. 8. T Locker, S Mason, A
Rigby. Headache managementóAre we doing enough? An observational study of
patients presenting with headache to the emergency department. Emerg Med J
2004;21:327ñ332.14. 9. Literature Reviews: Imaging Efficiency Measures.
Accessed at:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228749296370.
Accessed on August 21, 2012. (Submitted by: American College of Emergency
Physicians (ACEP) Quality and Performance Committee)
- [Pre-workgroup meeting comment] The FAH is surprised to see this
measure reappear on the MUC list. We lookat at a similar measure in previous
years and opposed it at that point at OP-15. First, there is not a clinical
evidence base to support performance measurement of CT imaging in Medicare
beneficiaries with headache. Hospitals work with clinicians to ACEP is
actively engaged in work to address inappropriate use of imaging. We believe
careful consideration should be given to age of the patient and potential risk
factors that would indicate the need for imaging. To our knowledge there is
not a clinical decision rule or other evidence based tool that clinicians
should use to ìimproveî their performance on a measure of this nature. Second,
the FAH believes this type of administrative measure should also be validated
by chart review. While the measure developer has taken steps to risk adjust
this measure, we are not convinced that the measure accurately or reliably
characterize patient complaints and comorbidities. Third, FAH is concerned
that the implementation of OP-15 would create pressure for hospitals and
emergency clinicians to reduce the use of brain CT in this older population
who are at high-risk of having significant intracranial findings, without any
evidence as to how to do so safely or appropriately. The recommendation of
such a measure should be based on evidence that the risk of adverse outcomes
(e.g. intracranial hemorrhage or stroke within several weeks). (Submitted by:
Federation of American Hospitals)