NQF

Version Number: 3.6
Meeting Date: January 26-27, 2016

Measure Applications Partnership
Coordinating Committee Discussion Guide

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Agenda

Agenda Synopsis

Day 1: January 26, 2016  
9:30 AM   Breakfast
10:00 AM   Welcome and Review of Meeting Objectives
10:30 AM   MAP Pre-Rulemaking Approach Updates
11:30 AM   MAP Pre-Rulemaking Strategic Issues
12:30 PM   Opportunity for Public Comment
12:45 PM   Lunch

1:15 PM   Pre-Rulemaking Recommendations for PAC/LTC Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
   Measures Identified for Discussion (No Vote Required)
   Finalizing Workgroup Recommendations for All PAC/LTC Programs
2:15 PM   Opportunity for Public Comment

2:30 PM   Pre-Rulemaking Recommendations for Clinician Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
   Measures Identified for Discussion (No Vote Required)
   Finalizing Workgroup Recommendations for All Clinician Programs
3:30 PM   Break

3:45 PM   Opportunity for Public Comment
4:45 PM   Opportunity for Public Comment
5:00 PM   Adjourn for the Day

Day 2: January 27, 2016  
9:00 AM   Breakfast
9:15 AM   Day 1 Recap
9:30 AM   Pre-Rulemaking Recommendations for Hospital Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
   Finalizing Workgroup Recommendations for All Hospital Programs
10:30 AM   Break
10:45 AM   MAP at 5 Years: Vision for the Future
11:45 AM   Discussion of MAP Core Concepts – Breakout Sessions
12:00 PM   Lunch
12:30 PM   Finalization of MAP Core Concepts
1:30 PM   Round-Robin Discussion: Improving MAP’s Processes
2:00 PM   Opportunity for Public Comment
2:15 PM   Closing Remarks
2:30 PM   Adjourn


Full Agenda

Day 1: January 26, 2016  
9:30 AM   Breakfast
10:00 AM   Welcome and Review of Meeting Objectives
Beth McGlynn, MAP Coordinating Committee Co-Chair
Harold Pincus, MAP Coordinating Committee Co-Chair

10:30 AM   MAP Pre-Rulemaking Approach Updates
Erin O’Rourke, Senior Director, NQF
Beth McGlynn
  • Review the 2015-2016 MAP Pre-Rulemaking Approach
  • Discuss the implementation of measures under development pathway
  • Discuss the process to consider of gap filling measures


11:30 AM   MAP Pre-Rulemaking Strategic Issues
Taroon Amin, NQF Consultant
Harold Pincus
  • Review the Risk-adjustment of Measures for Socioeconomic Status (SES) Trial Period
  • Discuss attribution and shared accountability
  • Discuss the importance of feedback loops


12:30 PM   Opportunity for Public Comment
12:45 PM   Lunch

1:15 PM   Pre-Rulemaking Recommendations for PAC/LTC Programs
Carol Raphael, Workgroup Co-Chair
Sarah Sampsel, Senior Director, NQF
Erin O’Rourke
Beth McGlynn
  • Discuss key themes from the PAC/LTC Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
  1. Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) (required by PAMA) (MUC ID: MUC15-1048)
    • Description: All-condition risk-adjusted potentially preventable hospital readmission rates (required under PAMA) (Measure Specifications)
    • Programs under consideration: Skilled Nursing Facility Value-Based Purchasing Program
    • Public comments received: 11
    • Workgroup Rationale: MAP members raised concerns about potential negative unintended consequences if SNFs are hesitant to transfer patients to the hospital to avoid penalties. Some MAP members noted the limited actionability of this measure and that increased granularity could provide information to improve care. However, other members stated that providers should implement their own systems for tracking and identifying these issues for quality improvement.CMS indicated that this measure would replace the current all-cause readmission as soon as practical.
    • Workgroup Recommendation: Encourage continued development


  2. Falls risk composite process measure (MUC ID: MUC15-207)
    • Description: Percentage of patients who were assessed for falls risk and whose care plan reflects the assessment and was implemented as appropriate. (Measure Specifications)
    • Programs under consideration: Home Health Quality Reporting Program
    • Public comments received: 12
    • Workgroup Rationale: MAP noted that this composite measure addresses falls risk and related clinical intervention assessments, which are considered safety measures and meet the goals of the Home Health QRP.
    • Workgroup Recommendation: Encourage continued development


  3. Hospice and Palliative Care Composite Process Measure (MUC ID: MUC15-231)
    • Description: This measure will assess percentage of hospice patients who received care processes consistent with guidelines at admission. This is a composite measure based on select measures from 7 NQF-endorsed measures: NQF #1641, NQF #1647, NQF #1634, NQF #1637, NQF #1639, NQF #1638, NQF #1617. (Measure Specifications)
    • Programs under consideration: Hospice Quality Reporting Program
    • Public comments received: 19
    • Workgroup Rationale: Although MAP encouraged continued development, members noted the need to balance this measure with what is relevant to the patient, and not limit to only check box quality measures.
    • Workgroup Recommendation: Encourage continued development


  4. Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) (MUC ID: MUC15-236)
    • Description: This quality measure estimates the risk-adjusted mean change in self-care score between admission and discharge among SNF residents. (The endorsed specifications of the measure are: This measure estimates the risk-adjusted mean change in self-care score between admission and discharge for Inpatient Rehabilitation Facility (IRF) Medicare patients.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Skilled Nursing Facility Quality Reporting System
    • Public comments received: 17
    • Workgroup Rationale: The functional status measures are adaptations of currently endorsed measures for the IRF population. MAP encouraged continued development to ensure alignment across PAC settings, but also noted there should be some caution in interpretation of measure results due to patient differentiation between facilities.MAP also stressed the importance of considering burden on providers when measures are considered for implementation.
    • Workgroup Recommendation: Encourage continued development


  5. Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-1127)
    • Description: Percentage of stays Inpatient Rehabilitation Facility (IRF), Long Term Care Facility (LTCH), and Skilled Nursing Facility (SNF) or care episodes Home Health (HH) in which a drug regimen review was conducted at the Admission (IRF, LTCH or SNF)/ Start of Care (SOC)/ Resumption of Care (ROC) (HH) and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout the stay (IRF, LTCH, or SNF) or care episode (HH). (Measure Specifications)
    • Programs under consideration: Home Health Quality Reporting Program
    • Public comments received: 11
    • Workgroup Rationale: MAP noted the importance of medication reconciliation but raised concerns and asked for greater clarity about the definition of reconciliation versus drug regimen review. Members also noted the challenge of defining some of the measure components, specifically “a clinically significant issue” given the large number of medications a patient may be taking. MAP stressed that medication reconciliation is a step in a drug regimen review and asked for greater clarity on defining the drug regimen review process. MAP stressed the importance of conducting a complete medication review from all sites of care, including the home. MAP members noted the value of the role of family caregivers in providing this information and the hope that technology can help to minimize the burden of getting this information. MAP members asked for greater emphasis of the inclusion of non-prescription medication (including supplements), noting that this is a particular concern in the PAC/LTC population.MAP members raised some concerns about the feasibility of this measure and noted the need to clarify the roles of the interdisciplinary team. MAP noted the importance of attribution issues for this measure. Additionally, Workgroup members raised concerns about the challenges of competing guidelines and need for greater clarity about when a medication can be withdrawn. MAP stressed that medication reconciliation needs to be an on-going process. MAP also noted that this is a particular concern for dual-eligible beneficiaries.
    • Workgroup Recommendation: Encourage continued development


  6. Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-1128)
    • Description: Percentage of stays Inpatient Rehabilitation Facility (IRF), Long Term Care Facility (LTCH), and Skilled Nursing Facility (SNF) or care episodes Home Health (HH) in which a drug regimen review was conducted at the Admission (IRF, LTCH or SNF)/ Start of Care (SOC)/ Resumption of Care (ROC) (HH) and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout the stay (IRF, LTCH, or SNF) or care episode (HH). (Measure Specifications)
    • Programs under consideration: Inpatient Rehabilitation Facility Quality Reporting Program
    • Public comments received: 8
    • Workgroup Rationale: MAP noted the importance of medication reconciliation but raised concerns and asked for greater clarity about the definition of reconciliation versus drug regimen review. Members also noted the challenge of defining some of the measure components, specifically “a clinically significant issue” given the large number of medications a patient may be taking. MAP stressed that medication reconciliation is a step in a drug regimen review and asked for greater clarity on defining the drug regimen review process. MAP stressed the importance of conducting a complete medication review from all sites of care, including the home. MAP members noted the value of the role of family caregivers in providing this information and the hope that technology can help to minimize the burden of getting this information. MAP members asked for greater emphasis of the inclusion of non-prescription medication (including supplements), noting that this is a particular concern in the PAC/LTC population.MAP members raised some concerns about the feasibility of this measure and noted the need to clarify the roles of the interdisciplinary team. MAP noted the importance of attribution issues for this measure. Additionally, Workgroup members raised concerns about the challenges of competing guidelines and need for greater clarity about when a medication can be withdrawn. MAP stressed that medication reconciliation needs to be an on-going process. MAP also noted that this is a particular concern for dual-eligible beneficiaries.
    • Workgroup Recommendation: Encourage continued development


  7. Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-1129)
    • Description: Percentage of stays Inpatient Rehabilitation Facility (IRF), Long Term Care Facility (LTCH), and Skilled Nursing Facility (SNF) or care episodes Home Health (HH) in which a drug regimen review was conducted at the Admission (IRF, LTCH or SNF)/ Start of Care (SOC)/ Resumption of Care (ROC) (HH) and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout the stay (IRF, LTCH, or SNF) or care episode (HH). (Measure Specifications)
    • Programs under consideration: Long-Term Care Hospital Quality Reporting Program
    • Public comments received: 4
    • Workgroup Rationale: MAP noted the importance of medication reconciliation but raised concerns and asked for greater clarity about the definition of reconciliation versus drug regimen review. Members also noted the challenge of defining some of the measure components, specifically “a clinically significant issue” given the large number of medications a patient may be taking. MAP stressed that medication reconciliation is a step in a drug regimen review and asked for greater clarity on defining the drug regimen review process. MAP stressed the importance of conducting a complete medication review from all sites of care, including the home. MAP members noted the value of the role of family caregivers in providing this information and the hope that technology can help to minimize the burden of getting this information. MAP members asked for greater emphasis of the inclusion of non-prescription medication (including supplements), noting that this is a particular concern in the PAC/LTC population.MAP members raised some concerns about the feasibility of this measure and noted the need to clarify the roles of the interdisciplinary team. MAP noted the importance of attribution issues for this measure. Additionally, Workgroup members raised concerns about the challenges of competing guidelines and need for greater clarity about when a medication can be withdrawn. MAP stressed that medication reconciliation needs to be an on-going process. MAP also noted that this is a particular concern for dual-eligible beneficiaries.
    • Workgroup Recommendation: Encourage continued development


  8. Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-1130)
    • Description: Percentage of stays Inpatient Rehabilitation Facility (IRF), Long Term Care Facility (LTCH), and Skilled Nursing Facility (SNF) or care episodes Home Health (HH) in which a drug regimen review was conducted at the Admission (IRF, LTCH or SNF)/ Start of Care (SOC)/ Resumption of Care (ROC) (HH) and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout the stay (IRF, LTCH, or SNF) or care episode (HH). (Measure Specifications)
    • Programs under consideration: Skilled Nursing Facility Quality Reporting System
    • Public comments received: 11
    • Workgroup Rationale: MAP noted the importance of medication reconciliation but raised concerns and asked for greater clarity about the definition of reconciliation versus drug regimen review. Members also noted the challenge of defining some of the measure components, specifically “a clinically significant issue” given the large number of medications a patient may be taking. MAP stressed that medication reconciliation is a step in a drug regimen review and asked for greater clarity on defining the drug regimen review process. MAP stressed the importance of conducting a complete medication review from all sites of care, including the home. MAP members noted the value of the role of family caregivers in providing this information and the hope that technology can help to minimize the burden of getting this information. MAP members asked for greater emphasis of the inclusion of non-prescription medication (including supplements), noting that this is a particular concern in the PAC/LTC population.MAP members raised some concerns about the feasibility of this measure and noted the need to clarify the roles of the interdisciplinary team. MAP noted the importance of attribution issues for this measure. Additionally, Workgroup members raised concerns about the challenges of competing guidelines and need for greater clarity about when a medication can be withdrawn. MAP stressed that medication reconciliation needs to be an on-going process. MAP also noted that this is a particular concern for dual-eligible beneficiaries.
    • Workgroup Recommendation: Encourage continued development


  9. Medicare Spending Per Beneficiary-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-1134)
    • Description: The MSPB-PAC Measure for HHAs evaluates providers’ efficiency relative to the efficiency of the national median HHA provider. Specifically, the MSPB-PAC Measure assesses the cost to Medicare for services during an episode of care, which consists of a treatment period and an associated services period. The episode is triggered by the initiation of a 60 day HHA service period. The treatment period begins at the trigger and ends on the last day of the service period. The associated services period begins at the trigger and ends 30 days after the end of the treatment period. These periods constitute the episode window during which beneficiaries’ Medicare services are counted toward the episode. The MSPB-PAC episode includes all services during the episode window that are attributable to the HHA provider and those rendered by other providers, except those services during the associated services period that are clinically unrelated to HHA responsibilities (e.g., planned care and routine screening). (Measure Specifications)
    • Programs under consideration: Home Health Quality Reporting Program
    • Public comments received: 10
    • Workgroup Rationale: Members noted the importance of balancing cost measures with quality and access. Although the MAP encouraged continued development, they did note concerns about the potential for unintended consequences. In particular, the group raised concerns about issues of premature discharges. The group noted this could put a tremendous burden on family caregivers who may have to care for a patient they are not fully able to support. Members also noted the need to consider risk adjustment for severity and socioeconomic status.
    • Workgroup Recommendation: Encourage continued development


  10. Medicare Spending per Beneficiary-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-287)
    • Description: The MSPB-PAC Measure for IRFs evaluates providers’ efficiency relative to the efficiency of the national median IRF provider. Specifically, the MSPB-PAC Measure assesses the cost to Medicare for services during an episode of care, which consists of a treatment period and an associated services period. The episode is triggered by an admission to an IRF stay. The treatment period begins at the trigger and ends at discharge. The associated services period begins at the trigger and ends 30 days after the end of the treatment period (i.e., discharge). These periods constitute the episode window during which beneficiaries’ Medicare services are counted toward the episode. The MSPB-PAC episode includes all services during the episode window that are attributable to the IRF provider and those rendered by other providers, except those services during the associated services period that are clinically unrelated to IRF responsibilities (e.g., planned care and routine screening). (Measure Specifications)
    • Programs under consideration: Inpatient Rehabilitation Facility Quality Reporting Program
    • Public comments received: 12
    • Workgroup Rationale: MAP noted that socioeconomic status is a particular concern for IRFs. Patients need social supports to be able to return to the community with a disability. Additionally, it was suggested that providers who are teaching facilities and serve low income patients may have higher costs than others.
    • Workgroup Recommendation: Encourage continued development


  11. Medicare Spending per Beneficiary-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-289)
    • Description: The MSPB-PAC Measure for LTCHs evaluates providers’ efficiency relative to the efficiency of the national median LTCH provider. Specifically, the MSPB-PAC Measure assesses the cost to Medicare for services during an episode of care, which consists of a treatment period and an associated services period. The episode is triggered by an admission to an LTCH stay. The treatment period begins at the trigger and ends at discharge. The Measure is constructed differently for cases in which the LTCH stay is paid according to the standard MS-LTC-DRG versus cases in which the LTCH stay is paid a site neutral rate comparable to the IPPS payment rates. The associated services period for standard payment rate cases begins at the trigger and ends 30 days after the end of the treatment period (i.e., discharge). The associated services period for site neutral payment rate cases begins at the close of the treatment period and ends 30 days after, to parallel the MSPB-Hospital measure. For the standard and site neutral cases, these periods constitute the episode window during which beneficiaries’ Medicare services are counted toward the episode. For the standard cases, the MSPB-PAC episode includes all services during the episode window that are attributable to the LTCH provider and those rendered by other providers, except those services during the associated services period that are clinically unrelated to LTCH responsibilities (e.g., planned care and routine screening). For the site neutral cases, the MSPB-PAC episode includes all services during the episode window that are attributable to the LTCH provider and those rendered by other providers, except those services during the associated services period that are clinically unrelated to LTCH responsibilities (e.g., planned care and routine screening). As discussed above, there is a difference in the construction of the associated services period for these cases, in that it only begins at discharge and ends 30 days after. (Measure Specifications)
    • Programs under consideration: Long-Term Care Hospital Quality Reporting Program
    • Public comments received: 8
    • Workgroup Rationale: Members noted the importance of balancing cost measures with quality and access. Although the MAP encouraged continued development, they did note concerns about the potential for unintended consequences.
    • Workgroup Recommendation: Encourage continued development


  12. Medicare Spending per Beneficiary-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-291)
    • Description: The MSPB-PAC Measure for SNFs evaluates providers’ efficiency relative to the efficiency of the national median SNF provider. Specifically, the MSPB-PAC Measure assesses the cost to Medicare for services during an episode of care, which consists of a treatment period and an associated services period. The episode is triggered by an admission to a SNF stay. The treatment period begins at the trigger and ends at discharge. The associated services period begins at the trigger and ends 30 days after the end of the treatment period (i.e., discharge). These periods constitute the episode window during which beneficiaries’ Medicare services are counted toward the episode. The MSPB-PAC episode includes all services during the episode window that are attributable to the SNF provider and those rendered by other providers, except those services during the associated services period that are clinically unrelated to SNF responsibilities (e.g., planned care and routine screening). (Measure Specifications)
    • Programs under consideration: Skilled Nursing Facility Quality Reporting System
    • Public comments received: 10
    • Workgroup Rationale: Members noted the importance of balancing cost measures with quality and access. Although the MAP encouraged continued development, they did note concerns about the potential for unintended consequences. The group also raised concerns about the impact on rural providers. Additionally, MAP raised concerns that measuring acute and post-acute care separately could discourage innovative partnerships between hospitals and PAC/LTC providers.
    • Workgroup Recommendation: Encourage continued development


Measures Identified for Discussion (No Vote Required)
This section of the meeting includes discussion on specific measures (no vote required) where MAP Coordinating Committee members would like to add themes to the recommendation rationale or better understand the workgroup deliberations.
  1. Discharge to Community-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-408)
    • Description: This measure describes the risk-standardized rate of Medicare fee-for-service (FFS) patients/residents/persons who are discharged to the community following a post-acute stay/episode, and do not have an unplanned (re)admission to an acute care hospital or LTCH in the 31 days following discharge to community, and remain alive during the 31 days following discharge to community. (Measure Specifications)
    • Programs under consideration: Inpatient Rehabilitation Facility Quality Reporting Program
    • Public comments received: 14
    • Workgroup Rationale: MAP noted that available discharge codes and coding practices could cause confusion about the results of this measure and could also introduce validity concerns. MAP asked for greater clarity about the intent of these measures, especially how they may impact patients and consumers. MAP members raised concerns about the multiple ways that readmissions are being measured and noted that a provider could potentially be penalized multiple times for the same occurrence. MAP noted the need for excluding patients who are admitted to hospice to prevent discouraging discharges to hospice. MAP also noted that discharge to community can reflect access to social support and the measure may need to reflect this. MAP indicated the need for these measures to be submitted for NQF review and endorsement to address psychometric concerns about the measures.MAP members noted concerns about the risk adjustment of these measures, particularly for the home health setting. MAP specifically noted the need to appropriately risk adjust the measures to avoid unintended consequences.
    • Workgroup Recommendation: Encourage continued development


  2. Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-414)
    • Description: This measure describes the risk-standardized rate of Medicare fee-for-service (FFS) patients/residents/persons who are discharged to the community following a post-acute stay/episode, and do not have an unplanned (re)admission to an acute care hospital or LTCH in the 31 days following discharge to community, and remain alive during the 31 days following discharge to community. (Measure Specifications)
    • Programs under consideration: Long-Term Care Hospital Quality Reporting Program
    • Public comments received: 12
    • Workgroup Rationale: MAP noted that available discharge codes and MAP noted that available discharge codes and coding practices could cause confusion about the results of this measure and could also introduce validity concerns. MAP asked for greater clarity about the intent of these measures, especially how they may impact patients and consumers. MAP members raised concerns about the multiple ways that readmissions are being measured and noted that a provider could potentially be penalized multiple times for the same occurrence. MAP noted the need for excluding patients who are admitted to hospice to prevent discouraging discharges to hospice. MAP also noted that discharge to community can reflect access to social support and the measure may need to reflect this. MAP indicated the need for these measures to be submitted for NQF review and endorsement to address psychometric concerns about the measures.MAP members noted concerns about the risk adjustment of these measures, particularly for the home health setting. MAP specifically noted the need to appropriately risk adjust the measures to avoid unintended consequences.
    • Workgroup Recommendation: Encourage continued development


  3. Discharge to Community-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (MUC ID: MUC15-462)
    • Description: This measure describes the risk-standardized rate of Medicare fee-for-service (FFS) patients/residents/persons who are discharged to the community following a post-acute stay/episode, and do not have an unplanned (re)admission to an acute care hospital or LTCH in the 31 days following discharge to community, and remain alive during the 31 days following discharge to community. (Measure Specifications)
    • Programs under consideration: Skilled Nursing Facility Quality Reporting System
    • Public comments received: 14
    • Workgroup Rationale: MAP noted that available discharge codes and coding practices could cause confusion about the results of this measure and could also introduce validity concerns. MAP asked for greater clarity about the intent of these measures, especially how they may impact patients and consumers. MAP members raised concerns about the multiple ways that readmissions are being measured and noted that a provider could potentially be penalized multiple times for the same occurrence. MAP noted the need for excluding patients who are admitted to hospice to prevent discouraging discharges to hospice. MAP also noted that discharge to community can reflect access to social support and the measure may need to reflect this. MAP indicated the need for these measures to be submitted for NQF review and endorsement to address psychometric concerns about the measures.MAP members noted concerns about the risk adjustment of these measures, particularly for the home health setting. MAP specifically noted the need to appropriately risk adjust the measures to avoid unintended consequences.
    • Workgroup Recommendation: Encourage continued development


   Finalizing Workgroup Recommendations for All PAC/LTC Programs
This section of the meeting finalizes the remaining workgroup recommendations for:

2:15 PM   Opportunity for Public Comment

2:30 PM   Pre-Rulemaking Recommendations for Clinician Programs
Bruce Bagley, Workgroup Chair
Eric Whitacre, Workgroup Chair
Reva Winkler, Senior Director, NQF
Andrew Lyzenga, Senior Director, NQF
Harold Pincus
  • Discuss key themes from the Clinician Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
  1. Surveillance colonoscopy for dysplasia in colonic Crohns Disease (MUC ID: MUC15-212)
    • Description: Percentage of patients with diagnosis of colonic Crohn’s Disease for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: Crohn's disease is a chronic inflammatory disease of the digestive tract. Symptoms include abdominal pain and diarrhea, sometimes bloody, and weight loss. Crohn’s patients are at higher risk for colon cancer. American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend that patients with Crohn’s Disease for more than 10 years should have a surveillance colonoscopy every 1-2 years. Although there are no measures that focus on Crohn’s Disease in the current measures set and this measure would complement other colonoscopy measures MAP is concerned that the measure could be better specified to discourage overuse as well as encourage appropriate use of endoscopy. Comments from the American Gastroenterological Association do not support this measure and American Society for Gastrointestinal Endoscopy commented "While ASGE finds the inclusion of surveillance measures in public reporting programs worthy of exploration, this measure, as specified, would not deter overutilization of colonoscopy. The recommendations for surveillance colonoscopy in Crohn’s disease are based on how long the patient has had the disease."
    • Workgroup Recommendation: Do not encourage further consideration


  2. NMSC: Biopsy Reporting Time - Pathologist (MUC ID: MUC15-216)
    • Description: Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 7
    • Workgroup Rationale: MAP does not encourage further consideration of this measure for accountability programs. This "behind the scenes" measure is appropriate for quality improvement and systems improvement.
    • Workgroup Recommendation: Do not encourage further consideration


  3. Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (MUC ID: MUC15-229)
    • Description: Percentage of Patients aged 18 years and older with a diagnosis of hepatitis C who have completed a full course of antiviral treatment with undetectable hepatitis C virus (HCV) ribonucleic acid (RNA) 11 weeks after cessation of treatment. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: This is an intermediate outcome that reflects the treatment for Hepatitis C. Recent studies report that combining several oral antivirals—drugs taken in pill form, not as injections—clear the virus from the liver in more than 95% of people in just 12 weeks. The new medications are very expensive though cost-effectiveness studies conclude that treatment is cost-effective in most patients. This measure only captures patients that begin treatment – patient that cannot afford the medications are not included. This is an intermediate outcome measure related to process measure PQRS#087/NQF #0398 Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment. MAP encourages continued development but noted that data on current performance would provide a better understanding of gap in care. Public comments on this measure were mixed with some strongly supporting and other not.
    • Workgroup Recommendation: Encourage continued development


  4. Screening endoscopy for varices in patients with cirrhosis (MUC ID: MUC15-251)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented endoscopy (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 6
    • Workgroup Rationale: Esophageal varices (dilated veins) are a serious complications of cirrhosis of the liver. Screening for varices allows treatment to prevent variceal hemorrhage. Endoscopy is the standard for diagnosing varices. AASLD guidelines recommend endoscopy at the time of diagnosis when the prevalence of medium/large varices is 15-25% (Class IIa, Level C evidence.) Follow up screening every 1-2 years is recommended depending on the initial findings. If patients have small varices, follow up endoscopy is not necessary. All recommendations are Level C evidence so there is little empirical evidence that screening endoscopy will impact patient outcomes. Endoscopy carries significant costs, so evidence-based indications are needed. MAP does not encourage continued development because while this measure would address a new topic area in the set, the screening recommendation is not based on solid empirical evidence. The submitter did not provide any information on opportunity for improvement. Comments from the American Gastroenterological Association do not support this measure and American Society for Gastrointestinal Endoscopy commented "ASGE does not support advancement of this measure as specified. This measure would not deter overutilization of colonoscopy. Most guidelines suggest screening every 3 years in cirrhotic and within a year if they are decompensated."
    • Workgroup Recommendation: Do not encourage further consideration


  5. Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (MUC ID: MUC15-275)
    • Description: The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 5
    • Workgroup Rationale: Composite measures of evidence-based processes and intermediate clinical outcomes combine multiple factors important to care and address whether a patients is receiving all the evidence-based care they receive. Most of the atherosclerotic disease measures enjoy high performance individually, but the composite reveals that the results are not uniformly high for individual patients. Opportunity for improvement exists which can further reduce the risks of poor outcomes for patients and represents a measure that promotes high performance. CMS recently removed PQRS #349 (NQF#0076) Optimal Vascular Care - an all-or-none-composite measure - because it is duplicative of the Millions Hearts measures. MAP supports use of both a composite measure as well as the individual measures for the Millions Hearts campaign. This measure, MUC15-275 is a competing measure with PQRS #349 (NQF#0076) – both are all-or-none composite measures for ischemic vascular disease. NQF will be evaluating both measures side-by-side in the upcoming Cardiovascular - Phase 4 project. CONDITION: MAP conditionally supports this measure pending the outcome of the NQF evaluation of both composite measures. MAP supports inclusion of the composite measure that is considered best-in-class by the NQF review.
    • Workgroup Recommendation: Conditional support


  6. Prevention Quality Indicators 92 Prevention Quality Chronic Composite (MUC ID: MUC15-576)
    • Description: PQI composite of chronic conditions 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, or angina without a cardiac procedure. (Includes PQIs 1, 3, 5, 7, 8, 13, 14, 15, and 16) (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: This composite measure combines AHRQ's PQI individual measures for admissions for several chronic conditions. This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. MAP encourages continued development and testing of this measure with attention to applicability at the clinician level of analysis and the risk-adjustment model under development. MAP suggests considering sociaodemographic factors also. CMS advised MAP that this composite is already used in the Physician Value Modifier Program.
    • Workgroup Recommendation: Encourage continued development


  7. Prevention Quality Indicators 92 Prevention Quality Chronic Composite (MUC ID: MUC15-576)
    • Description: PQI composite of chronic conditions 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, or angina without a cardiac procedure. (Includes PQIs 1, 3, 5, 7, 8, 13, 14, 15, and 16) (Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 9
    • Workgroup Rationale: This composite measure combines AHRQ's PQI individual measures for admissions for several chronic conditions. This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. MAP encourages continued development and testing of this measure with attention to applicability at the ACO level of analysis and the risk-adjustment model under development. MAP suggests considering sociodemographic factors also. CMS advised MAP that this composite is already used in the Physician Value Modifier Program.
    • Workgroup Recommendation: Encourage continued development


  8. PQI 91 Prevention Quality Acute Composite (MUC ID: MUC15-577)
    • Description: PQI composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection. (Includes PQIs 10, 11, and 12) (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: This composite measure combines AHRQ's PQIs individual measures for three acute conditions. MAP encourages continued development of this composite with testing at the clinician level with the new risk-adjustment model that includes co-morbidities. This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. This measure encourages appropriate care of acute conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families. However, MAP raised concerns about the potential for promoting antibiotic overuse such as overtreatment for aspiration pneumonia particularly in patients residing in nursing homes and unnecessary treatment for asymptomatic bactiuria. MAP questioned whether there could be interaction of this measure with the hospital acquired condition(HACs)measures - the developer responded that the present on admission codes used for these measures are excluded for the HACs. CMS advised MAP that this composite is already used in the Physician Value Modifier Program. CMS advised that they are considering attribution and geographical comparisons.
    • Workgroup Recommendation: Encourage continued development


  9. PQI 91 Prevention Quality Acute Composite (MUC ID: MUC15-577)
    • Description: PQI composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection. (Includes PQIs 10, 11, and 12) (Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 7
    • Workgroup Rationale: This composite measure combines AHRQ's PQIs individual measures for three acute conditions. MAP encourages continued development of this composite with testing at the ACO level with the new risk-adjustment model that includes co-morbidities. This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. This measure encourages appropriate care of acute conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families. However, MAP raised concerns about the potential for promoting antibiotic overuse such as overtreatment for aspiration pneumonia particularly in patients residing in nursing homes and unnecessary treatment for asymptomatic bactiuria. MAP questioned whether there could be interaction of this measure with the hospital acquired condition(HACs)measures - the developer responded that the present on admission codes used for these measures are excluded for the HACs. CMS advised MAP that this composite is already used in the Physician Value Modifier Program.
    • Workgroup Recommendation: Encourage continued development


  10. Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (MUC ID: MUC15-579)
    • Description: This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates: A) Screening for Future Fall Risk: Percentage of patients aged 65 years of age and older who were screened for future fall risk at least once within 12 months; B) Falls: Risk Assessment: Percentage of patients aged 65 years of age and older with a history of falls who had a risk assessment for falls completed within 12 months; C) Plan of Care for Falls: Percentage of patients aged 65 years of age and older with a history of falls who had a plan of care for falls documented within 12 months. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 7
    • Workgroup Rationale: Prevention of falls is a cross-cutting, patient safety measure applicable to all Medicare patients. This NQF-endorsed measure is aligned with PQRS.
    • Workgroup Recommendation: Support


  11. Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (MUC ID: MUC15-928)
    • Description: This three-component paired measure assesses whether the PHQ-9 screening tool was used among patients with a diagnosis of major depression or dysthymia, and using patient reports, whether patients with an initial PHQ score >9 demonstrate remission (i.e., PHQ score >5) at six or 12 months. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression.1 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. There is an opportunity for improvement for the population captured by this paired measure, which includes two PROs. MAP noted that the clinician set contains measure NQF#710/PQRS#370 Depression Remission at Twelve months and NQF#712 and PQRS#371Depressison Utilization of the PHQ-9. CMS advised that the public-private collaboration ongoing to development core sets of measures to foster better alignment will include measures NQF#710/PQRS#370 and NQF#1895 Assessment of mental status for community-acquired bacterial pneumonia. This NQF-endorsed measure is a patient-reported outcome. This updated three-part measure consolidates two current measures in the PQRS and Meaningful Use programs. MAP was advised that the data collected for the current measures can be used for this measures without additional burden. MAP also notes that this new measure is more aggressive that the current measures and supports this measure with the following CONDITIONS: look at the response rates; consider risk-stratification to minimize adverse selection; consider target rates for different types of providers and consider alignment with the core measures.
    • Workgroup Recommendation: Conditional Support


  12. Screening for Hepatoma in patients with Chronic Hepatitis B (MUC ID: MUC15-217)
    • Description: Percentage of patients with a diagnosis of Chronic Hepatitis B that have had a documented abdominal US, CT Scan, or MRI in the measurement period (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: This measure addresses a new topic area of Hepatitis B and is related to PQRS# 401 Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis. A systematic review of Screening for Hepatocellular Carcinoma in Chronic Liver Disease concluded that “There is very-low-strength evidence about the effects of HCC screening on mortality in patients with chronic liver disease. Screening tests can identify early-stage HCC, but whether systematic screening leads to a survival advantage over clinical diagnosis is uncertain.” The frequency of imaging is not specified. MAP does not encourage further consideration because the current evidence indicates that the benefit to patients is uncertain. The costs of screening without evidence of a benefit are not justified. Comments from the American Gastroenterological Association do not support this measure and American Society for Gastrointestinal Endoscopy commented "ASGE does not support advancement of this measure at this time as the measure concept lacks sufficient evidence to show importance to measure and variation in performance."
    • Workgroup Recommendation: Do not encourage further consideration


Measures Identified for Discussion (No Vote Required)
This section of the meeting includes discussion on specific measures (no vote required) where MAP Coordinating Committee members would like to add themes to the recommendation rationale or better understand the workgroup deliberations.
  1. Hepatitis A vaccination for patients with cirrhosis (MUC ID: MUC15-210)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis A vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 9
    • Workgroup Rationale: The ACIP recommends Hepatitis A vaccination: "Although not at increased risk for Hep A infection, persons with chronic liver disease are at increased risk for fulminant hepatitis A. Death certificate data indicate a higher prevalence of chronic liver disease among persons who died of fulminant hepatitis A compared with persons who died of other causes. Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (ACIP 2014)MAP encouraged continued development of this measure but strongly recommends this measure be fully harmonized with PQRS#183/NQF#0399 Hepatitis C: Hepatitis vaccination or better yet, consolidate both into a single vaccination measure for patients with chronic liver disease as recommended by ACIP. The measure is duals sensitive. The registry is not specified. Data on current performance would provide a better understanding of the gap in care. Public comments on this measure were mixed with some strongly supporting and other not.
    • Workgroup Recommendation: Encourage continued development


  2. Hepatitis B vaccination for patients with chronic Hepatitis C (MUC ID: MUC15-220)
    • Description: Percentage of patients with diagnosis of chronic Hepatitis C that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 7
    • Workgroup Rationale: CDC recommends that all patients with chronic liver disease are vaccinated for hepatitis B. MAP encourages continued development with strong consideration to consolidating this measure as Hepatitis B vaccination for all patients with chronic liver disease, including hepatitis C as recommended by CDC, i.e., combine this measure with the MUC for Hepatitis B vaccination for patients with cirrhosis. Importantly, the specifications should specify that all doses of the vaccine should be given to get credit for this measure. This measure is duals sensitive. Data on current performance would provide better understanding of the gap in care. The registry is not specified. Public comments on this measure were mixed with some strongly supporting and other not.
    • Workgroup Recommendation: Encourage continued development


  3. Hepatitis B vaccination for patients with cirrhosis (MUC ID: MUC15-211)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 8
    • Workgroup Rationale: The CDC recommendation for Hepatitis B vaccination includes persons with chronic liver disease as a preventive health measure. MAP encourages continued development of this measures with strong consideration to focusing this measure on patients with chronic liver disease, including Hepatitis C, rather than multiple measures. The measure is duals sensitive. The registry is not specified. Data on current performance would provide a better understanding of the gap in care. Public comments on this measure were mixed with some strongly supporting and other not.
    • Workgroup Recommendation: Encourage continued development


  4. Over-utilization of mesh in the posterior compartment (MUC ID: MUC15-436)
    • Description: Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 6
    • Workgroup Rationale: Posterior repair with and without mesh have been compared with similar outcomes. Mesh has been shown to have significant complications including expulsion of the mesh in 17%. MAP encourages continued development of this measure that will promote reduced use of mesh and the associated costs (mesh and complications) without affecting patient outcomes. The measure adds an appropriate use measure to the group of measures for pelvic prolapse – a common condition in older women.
    • Workgroup Recommendation: Encourage continued development


   Finalizing Workgroup Recommendations for All Clinician Programs
This section of the meeting finalizes the remaining workgroup recommendations for:

3:30 PM   Break

3:45 PM   Opportunity for Public Comment
4:45 PM   Opportunity for Public Comment
5:00 PM   Adjourn for the Day

Day 2: January 27, 2016  
9:00 AM   Breakfast
9:15 AM   Day 1 Recap
Beth McGlynn
Harold Pincus

9:30 AM   Pre-Rulemaking Recommendations for Hospital Programs
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair
Ronald Walters, MAP Hospital Workgroup Co-Chair
Melissa Mariñelarena, Senior Director, NQF
Erin O’Rourke
Beth McGlynn
  • Discuss key themes from the Hospital Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
  1. Measurement of Phosphorus Concentration (MUC ID: MUC15-1136)
    • Description: Percentage of all peritoneal dialysis and hemodialysis patient months with serum or plasma phosphorus measured at least once within the month. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: End-Stage Renal Disease Quality Incentive Program
    • Public comments received: 6
    • Workgroup Rationale: MAP supported this measure, NQF #0255, because it tracks performance of a precursor process that is consistent with clinical guidelines to mitigate patient morbidity and mortality. The measure has been found to be reliable, valid, and not burdensome to calculate. This updated measure has been broadened to include pediatric patients and permit an alternative measurement mechanism, plasma phosphorous.
    • Workgroup Recommendation: Support


  2. ESRD Vaccination: Full-Season Influenza Vaccination (MUC ID: MUC15-761)
    • Description: Percentage of ESRD patients = 6 months of age on October 1 and on chronic dialysis = 30 days in a facility at any point between October 1 and March 31 who either received an influenza vaccination, were offered and declined the vaccination, or were determined to have a medical contraindication. (Measure Specifications)
    • Programs under consideration: End-Stage Renal Disease Quality Incentive Program
    • Public comments received: 9
    • Workgroup Rationale: MAP did not support this measure because there is no discussion of exclusions, and it does not address the inactivated vaccine. Additionally, there is a burden for staff to enter data into the database. MAP encouraged CMS to consider NQF #0226, which is NQF-endorsed, fully aligned, and fully tested.
    • Workgroup Recommendation: Do not support


  3. National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (MUC ID: MUC15-531)
    • Description: Assesses antimicrobial use (AU) in hospitals based on medication administration data hospitals collect electronically at the point of care and report via electronic file submissions to NHSN. AU data included in the measure are antibacterial agents administered to adult and pediatric patients in a specified set of hospital ward and intensive care unit locations. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 10
    • Workgroup Rationale: MAP conditionally supported this measure since the measure developer stated that the measure is intended for use in the National Healthcare Safety Network (NHSN) and wishes to gain greater experience and gather more information before using it for reporting or payment. MAP recognized the high importance of antimicrobial stewardship and conditionally support the inclusion of this measure in the IQR program to allow for the opportunity for additional testing to address feasibility issues. However, MAP noted these issues should be addressed before the measure is reported on Hospital Compare.
    • Workgroup Recommendation: Conditional support, pending the Centers for Disease Control recommendation that the measure is ready for use in public reporting, and pending resubmission to MAP for review of implementation data


  4. Excess Days in Acute Care after Hospitalization for Pneumonia (MUC ID: MUC15-391)
    • Description: This measure assesses the difference (“excess”) between the average number of risk-adjusted days a hospital’s patients spend in an ED, observation, or readmission in the 30 days following a hospitalization for pneumonia (“predicted”) and the number of days in acute care that they would have been expected to spend if discharged from an average hospital. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 8
    • Workgroup Rationale: MAP conditionally supported this measure pending NQF review and endorsement. MAP also stated that the Standing Committee reviewing this measure should consider SDS factors that examine the true hospital vs. community role in readmissions and consider parsimony with regard to multiple pneumonia readmission measures.
    • Workgroup Recommendation: Conditional support, pending NQF review and endorsement and examination of SDS factors


  5. IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (MUC ID: MUC15-1083)
    • Description: Vaginal births per 1,000 deliveries by patients with previous Cesarean deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure). (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 8
    • Workgroup Rationale: MAP did not support this measure because it adds little value to this measure set since VBAC rates would be calculated using only CMS claims data.
    • Workgroup Recommendation: Do not support


  6. INR Monitoring for Individuals on Warfarin after Hospital Discharge (MUC ID: MUC15-1015)
    • Description: Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic International Normalized Ratio (INR) who had an INR test within 14 days of hospital discharge (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 9
    • Workgroup Rationale: MAP conditionally supported this measure an optional eCQM pathway and asked that its performance be monitored. MAP recognized that this is an important patient safety issue, but stated that it should be optional for hospitals because not all vendors may be able to support the implementation of this measure.
    • Workgroup Recommendation: Conditional support, pending optional eCQM pathway


  7. Adult Local Current Smoking Prevalence (MUC ID: MUC15-1013)
    • Description: Percentage of adult (age 18 and older) U.S. population that currently smoke, defined as adults who reported having smoked at least 100 cigarettes in their lifetime and currently smoke. (The endorsed specifications of the measure are: Percentage of adult (age 18 and older) U.S. population that currently smoke.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 11
    • Workgroup Rationale: MAP encouraged further development of this measure at the city and/or county level because the group recognized the importance of a community-based approach to decrease smoking. This type of county-based measure indicates the need for hospital collaboration with the surrounding community to work together to provide tobacco cessation.
    • Workgroup Recommendation: Encourage continued development


  8. Spinal Fusion Clinical Episode-Based Payment Measure (MUC ID: MUC15-837)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a Spinal Fusion IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 9
    • Workgroup Rationale: MAP did not support this measure because although cost is important to measure, data supporting variation in costs for this procedure was not provided. The group also noted that measuring resource use (cost) is different from appropriateness of care; the cost of a service is not indicative of quality care.
    • Workgroup Recommendation: Do not support


  9. Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (MUC ID: MUC15-835)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to an aortic aneurysm procedure inpatient (IP) stay and attributes them to the hospital where the index IP stay occurred. It includes abdominal aortic aneurysm and thoracic aortic aneurysm subtypes. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 8
    • Workgroup Rationale: MAP did not support this measure because although cost is important to measure, data supporting variation in costs for this procedure was not provided. The group also noted that measuring resource use (cost) is different from appropriateness of care; the cost of a service is not indicative of quality care.
    • Workgroup Recommendation: Do not support


  10. Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (MUC ID: MUC15-836)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a Cholecystectomy and Common Duct Exploration IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 7
    • Workgroup Rationale: MAP did not support this measure because although cost is important to measure, data supporting variation in costs for this procedure was not provided. The group also noted that measuring resource use (cost) is different from appropriateness of care; the cost of a service is not indicative of quality care.
    • Workgroup Recommendation: Do not support


  11. Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (MUC ID: MUC15-838)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a TURP IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 5
    • Workgroup Rationale: MAP did not support this measure because although cost is important to measure, data supporting variation in costs for this procedure was not provided. The group also noted that measuring resource use (cost) is different from appropriateness of care; the cost of a service is not indicative of quality care.
    • Workgroup Recommendation: Do not support


  12. Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (MUC ID: MUC15-1082)
    • Description: The measure estimates a facility-level risk-standardized readmission rate for unplanned, all-cause readmission within 30 days of discharge from an Inpatient Psychiatric Facility of adult Medicare fee-for-service (FFS) patients with a principal diagnosis of a psychiatric disorder. The performance period for the measure is 24 months. (Measure Specifications)
    • Programs under consideration: Inpatient Psychiatric Facility Quality Reporting Program
    • Public comments received: 8
    • Workgroup Rationale: MAP noted the importance of reducing readmissions for mental health conditions but recommended this measure be submitted for NQF review and endorsement. MAP recommended the Admissions and Readmissions Standing Committee pay particular attention to the influence of sociodemographic factors when reviewing this measure as access to community resources and supports can influence a patient's ability to manage mental and behavioral health issues on an outpatient basis.
    • Workgroup Recommendation: Conditional support, pending NQF review and endorsement and examination of SDS factors.


  13. Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (MUC ID: MUC15-1065)
    • Description: Overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder 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 alcohol or drug use disorder treatment at discharge. (The endorsed specifications of the measure are: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder 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 alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.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).) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Inpatient Psychiatric Facility Quality Reporting Program
    • Public comments received: 8
    • Workgroup Rationale: MAP recognized the importance of addressing this critical quality and public health concern. MAP noted that this process measure is a start to addressing the issue but recommended that outcome measures be quickly developed and implemented. MAP recommended that the developer consider expanding this measure to the under 18 population and that this measure be considered for implementation in the IQR program.
    • Workgroup Recommendation: Support


   Finalizing Workgroup Recommendations for All Hospital Programs
This section of the meeting finalizes the remaining workgroup recommendations for:

10:30 AM   Break
10:45 AM   MAP at 5 Years: Vision for the Future
Wunmi Isijola, Administrative Director, NQF
Harold Pincus
Taroon Amin
Erin O’Rourke
  • Discuss improved CDP/MAP alignment and how MAP can ensure scientific integrity of the measures it recommends
  • Discuss the impact of the NQF Intended Use project on the pre-rulemaking process


11:45 AM   Discussion of MAP Core Concepts – Breakout Sessions
12:00 PM   Lunch
12:30 PM   Finalization of MAP Core Concepts
1:30 PM   Round-Robin Discussion: Improving MAP’s Processes
Amber Sterling, Project Manager, NQF

2:00 PM   Opportunity for Public Comment
2:15 PM   Closing Remarks
Beth McGlynn
Harold Pincus

2:30 PM   Adjourn

Appendix A: Measure Information

Measure Index

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Hospital Acquired Condition Reduction Program

Home Health Quality Reporting Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Hospice Quality Reporting Program

Hospital Value-Based Purchasing Program

Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Rehabilitation Facility Quality Reporting Program

Long-Term Care Hospital Quality Reporting Program

Merit-Based Incentive Payment System (MIPS)

Medicare Shared Savings Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program

Skilled Nursing Facility Quality Reporting System

Skilled Nursing Facility Value-Based Purchasing Program

Full Measure Information

Toxic Anterior Segment Syndrome (TASS) Outcome (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC15-1047)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of the anterior segment of the eye, is a complication of anterior segment eye surgery that typically develops within 24 hours after surgery. Various contaminants, including those from surgical equipment or supplies, have been implicated as causes of TASS. Although most cases of TASS can be treated, the inflammatory response associated with TASS can cause serious damage to intraocular tissues, resulting in vision loss. Prevention requires careful attention to solutions, medications, and ophthalmic devices and to cleaning and sterilization of surgical equipment because of the numerous potential etiologies. Despite a recent focus on prevention, cases of TASS continue to occur, sometimes in clusters. The incidence of TASS is unknown, but frequencies of 1454 cases in approximately 69,000 surgeries (Bodnar et al, J Cataract Refract Surg. 2012 Nov;38(11):1902-10.) and 909 cases in 50,114 surgeries (Cutler et al, J Cataract Refract Surg. 2010 Jul;36(7):1073-80.) have been reported in cross-sectional studies in the literature. With millions of anterior segment surgeries being performed in the United States each year, measurement and public reporting have the potential to serve as an additional tool to drive further preventive efforts.

Measure Specifications




Avoidance of Utilization of High Ultrafiltration Rate (= 13 ml/kg/hour) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-758)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The measure focus is evidence-based, demonstrated as follows: • Health outcome: a rationale supports the relationship of the health outcome to processes or structures of care. Applies to patient-reported outcomes (PRO), including health-related quality of life/functional status, symptom/symptom burden, experience with care, health-related behavior. • Intermediate clinical outcome: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence that the measured intermediate clinical outcome leads to a desired health outcome. • Process: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence 4 that the measured process leads to a desired health outcome. • Structure: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence that the measured structure leads to a desired health outcome. • Efficiency: evidence not required for the resource use component.

Measure Specifications

Summary of NQF Endorsement Review




ESRD Vaccination: Full-Season Influenza Vaccination (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-761)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Influenza vaccination is universally recommended for all people aged 6 months and older. According to the CDC, seasonal influenza, which occurs between October and March/April of the following year, is associated with approximately 36,000 deaths and 226,000 hospitalizations annually. While overall rates of influenza infection are highest among children, rates of serious illness and mortality are highest among adults aged 65 years or older and children aged two years or younger as well as among immunocompromised patients, which include ESRD patients. The proposed influenza vaccination measure is a facility-level measure that applies to all dialysis patients. At the end of 2012 there were 413,725 patients being dialyzed, of whom 114,083 were new (incident) to dialysis.

Measure Specifications




Measurement of Phosphorus Concentration (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1136)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Consistent monitoring of phosphorus levels helps ensure regulation of patient morbidity and mortality, including stabilization of bone density, decreased bone pain, fracture prevention and decreased rates of arteriosclerosis and related conditions (e.g., stroke, heart attack). Routine blood tests will also aid in detection of and monitoring for abnormal states phosphorus balance in this especially vulnerable population. Among the 6,073 facilities that have at least one eligible patient, we generated the following statistics of their performance scores (based on the patient month) using the January – December 2013 CROWNWeb clinical data: mean (SD)=87% (18%); min=0%; max=100%; 25th percentile=86%; 50th percentile=92%; 75th percentile=96%. A description of the data is included in questions 1.1-1.7 under “Scientific Acceptability”. Disparity analyses were performed among the entire eligible adult population (n=518,127) to examine the difference in performance scores by sex, race, ethnicity, and age. In particular, for each facility, the percent of patient-months by demographic group (sex, race, ethnicity, age) was calculated. Then, the facilities were divided into quintiles (Q1-Q5) based on the percentage of patient-months in the particular demographic category (i.e., a facility with percentage of females similar to the national median will be included in quintile 3). The top 20% of facilities in terms of rank, based on the percentages of females, were classified as Q5, while the bottom 20% of facilities were classified as Q1. Average (mean) performance for the measure was calculated for each quintile, and the means were examined for trend across quintiles (Q1-Q5). The Cochran-Armitage test for trend was performed to assess disparities in performance scores. All the results for each group across quintiles were statistically significant (p<0.0001), which imply that there are statistically significant changes in performance scores depending on sex, race, ethnicity, and age. While these differences are statistically significant, we did not determine them to be clinically meaningful differences. The mean performance scores for percent of patient-months with a phosphorus measurement in each quintile, by demographic group, are presented below. Facility Level Quintiles by Population Group (Quintile 1-5): Female(Q1=85.6%; Q2=88.0%; Q3=87.6%; Q4=88.3%; Q5=84.5%; P<0.0001) White (Q1=86.4%; Q2=85.5%; Q3=87.2%; Q4=87.3%; Q5=87.6%; P<0.0001) Black (Q1=86.9%; Q2=87.4%; Q3=87.1%; Q4=86.0%; Q5=86.7%; P<0.0001) Hispanic (Q1=85.2%; Q2=89.1%; Q3=87.6%; Q4=86.1%; Q5=86.8%; P<0.0001) Age>=65 (Q1=83.2%; Q2=88.0%; Q3=87.6%; Q4=87.4%; Q5=87.9%; P<0.0001) (note: age <18 was too small to calculate quintiles). In healthy individuals, the kidney occupies an integral, multi-faceted role in the maintenance of calcium-phosphorus homeostasis. It follows that abnormalities of calcium-phosphorus regulation are exceedingly common in patients with advanced chronic kidney disease, which, indeed, most data indicate that only 25-35% of dialysis patients are able to maintain calcium in the suggested target range of 8.4-9.5 mg/dL (KDOQI 2003). Numerous studies have demonstrated the impact of prolonged calcium-phosphorus dysregulation on patient morbidity and mortality (KDOQI 2003), which can lead to progressive bone weakness, bone pain and increased susceptibility to fractures, and severe arteriosclerosis that can precipitate strokes, heart attacks, and other adverse cardiac events. Unfortunately, overt symptoms can often remain unmanifested in many but the most extreme disordered states of calcium-phosphorus dysregulation, which is why routine blood tests are necessary to detect and monitor abnormal states of calcium and phosphorus balance in this especially vulnerable population. National Kidney Foundation. 2003. "K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease," American Journal of Kidney Disease, 42 (Suppl 3): S17. Found at: http://www.kidney.org/professionals/kdoqi/guidelines_bone/index.htm

Measure Specifications

Summary of NQF Endorsement Review




Proportion of Patients with Hypercalcemia (NQF #1454) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1165)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
In 2011, total Medicare costs for the ESRD program were $34.3 billion, a 5.4% increase from 2010 [14]. Abnormalities in serum levels of calcium and phosphorus, which are markers of mineral and bone disorder, are common among ESRD patients. Numerous studies have demonstrated the association of prolonged calcium and phosphorus dysregulation on patient morbidity and mortality [2,1]. In March 2010, the C- TEP recommended that a quality measure (CPM) for the upper limit of total serum calcium be calculated as the proportion of patients (calculated as patient months) with 3-month rolling average of total serum calcium greater than 10.2 mg/dL. This recommendation is consistent with the value indicated by a TEP held in 2006 and with the 2003 KDOQI guidelines [1]. The TEP in 2013 also reviewed the measures and recommended no changes to the current threshold. Since 10.2 mg/dl is the considered the upper limit of the normal range in the majority of clinical laboratories, this measure is also consistent with the published KDIGO guidelines [2]. Review of the currently available literature and evidence indicates that observational cohort studies show a consistent adverse association of hypercalcemia with cardiovascular events and all-cause mortality [3-7]. Clinical data demonstrate the association of increased serum calcium with vascular [8,9] and valvular calcifications [10]. The basic science also supports a pathological role of high calcium in promoting soft tissue and vascular calcification [11-13]. Although there are no interventional studies demonstrating the benefit of correcting hypercalcemia, there was unanimous agreement among the 2010 C-TEP members that calcium concentrations >10.2 mg/dL place the patient at increased risk of poor outcomes. Current guidelines indicate that clinical decision should be based on trends rather than single laboratory values [2]. Therefore, it was unanimously agreed to use a three-month rolling average for the reporting period. 1c.4. Citations for data demonstrating high priority provided in 1a.3 1) National Kidney Foundation: K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. American Journal of Kidney Disease 2003 42:S1-S202 (suppl 3). 2) Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group: KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney International 2009 76 (Suppl 113): S1-S130. 3) Block GA, Klassen PS, Lazarus JM, et al. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. Journal of the American Society of Nephrology : JASN 2004 15:2208-18. 4) Young EW, Albert JM, Satayathum S, et al. Predictors and consequences of altered mineral metabolism: the Dialysis Outcomes and Practice Patterns Study. Kidney international 2005 67:1179-87. 5) Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney international 2006 70:771-80. 6) Kimata N, Albert JM, Akiba T, et al. Association of mineral metabolism factors with all-cause and cardiovascular mortality in hemodialysis patients: the Japan dialysis outcomes and practice patterns study. Hemodialysis international. International Symposium on Home Hemodialysis 2007 11:340-8. 7) Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases : the official journal of the National Kidney Foundation 2008 52:519-30. 8) Chertow G.M., Raggi P., Chasan-Taber S., Bommer J., Holzer H., Burke S.K. Determinants of progressive vascular calcification in haemodialysis patients. Nephrology Dialysis Transplantation 2004 19 (6), pp. 1489-1496. 9) Dhingra R, Sullivan LM, Fox CS, Wang TJ, D´Agostino RB Sr, Gaziano JM, Vasan RS: Relations of serum phosphorus and calcium levels to the incidence of cardiovascular disease in the community. Arch Intern Med 2007 167: 879–885. 10) Wang AY, Lam CW, Wang M, Chan IH, Lui SF, Sanderson JE. Is valvular calcification a part of the missing link between residual kidney function and cardiac hypertrophy in peritoneal dialysis patients? Clinical journal of the American Society of Nephrology 2009 4:1629-36. 11) Ketteler M, Schlieper G, Floege J. Calcification and cardiovascular health: new insights into an old phenomenon. Hypertension 2006 47:1027–1034. 12) Giachelli CM. Vascular calcification mechanisms. Journal of the American Society of Nephrology : JASN 2004 15:2959–2964. 13) Yang H, Curinga G, Giachelli CM. Elevated extracellular calcium levels induce smooth muscle cell matrix mineralization in vitro. Kidney Int. 2004;66(6):2293–2299. 14) U S Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013.

Measure Specifications

Summary of NQF Endorsement Review




Standardized Hospitalization Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-693)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
1b.1. Rationale Hospitalization rates are an important indicator of patient morbidity and quality of life. On average, dialysis patients are admitted to the hospital twice a year and spend an average of 11 days in the hospital per year (USRDS, 2014). Hospitalizations account for approximately 37 percent of total Medicare expenditures for ESRD patients. Measures of the frequency of hospitalization have the potential to help efforts to control escalating medical costs, and to play an important role in identifying potential problems and helping facilities provide cost-effective health care. 1c.4. Citations 1) U S Renal Data System, USRDS 2014 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014. 2) Wheeler J, Hirth R, Meyer K, Messana JM. Exploring preventable hospitalizations of dialysis patients. J Am Soc Nephrol 22, 2011. [3] Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Physician visits and 30-day hospital readmissions in patients receiving hemodialysis. J Am Soc Nephrol 25, 2014 (published online before print). [4] Arora P, Kausz AT, Obrador GT, Ruthazer R, Khan S, Jenuleson CS, Meyer KB, Pereira BJ. Hospital utilization among chronic dialysis patients. J Am Soc Nephrol 11: 740 –746, 2000. [5] Piraino B. Staphylococcus aureus infections in dialysis patients: focus on prevention. ASAIO J 46(6): S13-S17, 2000. [6] Dalrymple LS, Johansen KL, Romano PS, Chertow GM, Mu Y, Ishida JH, Grimes B, Kaysen GA, Nguyen DV. Comparison of hospitalization rates among for-profit and nonprofit dialysis facilities. Clin J Am Soc Nephrol 9, 2014 (published online before print).

Measure Specifications




Standardized Mortality Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-575)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
There is evidence indicating that mortality among black ESRD patients is lower than mortality for white ESRD patients, mortality for Hispanic ESRD patients is lower than mortality for non-Hispanic ESRD patients, and mortality for female ESRD patients is lower than mortality for male ESRD patients (see references below). Without a race adjustment, identical SMRs for one facility with predominantly white patients and one facility with predominantly black patients, for example, would give the false impression that quality of care at the two facilities was equivalent, when in fact adjusted mortality at the facility with more black patients would be lower if performance was identical. The SMR is adjusted for all three of these patient characteristics to avoid masking disparities in care across groups. To examine sociodemographic disparities we included quintiles of socioeconomic status (defined for each patient as the median zipcode code household income). This had little effect on the resulting expected deaths counts from the model. See the section on risk adjustment for further details. References: J Kalbfleisch, R Wolfe, S Bell, R Sun, J Messana, T Shearon, V Ashby, R Padilla, M Zhang, M Turenne, J Pearson, C Dahlerus, Y Li, 2015, “Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes” accepted for publication by JASN; Powe, NR. Reverse race and ethnic disparities in survival increase with severity of chronic kidney disease: What does this mean? Clin J Am Soc Nephrol 1: 905–906, 2006; Cowie CC, Port FK, Rust KF, Harris MI: Differences in survival between black and white patients with diabetic end-stage renal disease. Diabetes Care 17: 681–687, 1994).

Measure Specifications




Standardized Readmission Ratio (SRR) for dialysis facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1167)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Unplanned readmission rates are an important indicator of patient morbidity and quality of life. On average, dialysis patients are admitted to the hospital nearly twice a year and hospitalizations account for approximately 38 percent of total Medicare expenditures for dialysis patients (U.S. Renal Data System, 2012). In 2010, more than 30% of dialysis patient discharges from an all-cause hospitalization were followed by an unplanned readmission within 30 days (U.S. Renal Data System, 2012). Measures of the frequency of unplanned readmissions, such as SRR, help efforts to control escalating medical costs, play an important role in providing cost-effective health care, and support coordination of care across inpatient and outpatient settings: discharge planning, transition, and follow-up care. Studies have shown that pre- and post-discharge interventions may reduce admission and unplanned readmission rates. A variety of studies on non-ESRD populations that evaluated post-discharge interventions (Dunn 1994; Bostrom 1996; Dudas 2001; Azevedo 2002; Coleman 2004; Coleman 2006; Balaban 2008; Braun 2009) or a combination of pre- and post-discharge interventions (Naylor 1994; McDonald 2001; Creason 2001; Ahmed 2004; Anderson 2005; Jack 2009; Koehler 2009; Parry 2009) have indicated a reduction in the risk of unplanned readmissions to various degrees. In addition, a recent study in the ESRD population found that certain postdischarge assessments and changes in treatment at the dialysis facility may be associated with a reduced risk of readmission (Chan 2009). Altogether, these studies support the potential for modifying unplanned readmission rates with interventions performed prior to and immediately following patient discharge. Ahmed A, Thornton P, Perry GJ, Allman RM, DeLong JF. Impact of atrial fibrillation on mortality and readmission in older adults hospitalized with heart failure. Eur J Heart Fail. 2004;6(4):421–426. Anderson MA, Clarke MM, Helms LB, Foreman MD. Hospital readmission from home health care before and after prospective payment. J Nurs Scholarsh. 2005;37(1):73–79. Azevedo A, Pimenta J, Dias P, Bettencourt P, Ferreira A, Cerqueira-Gomes M. Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care. Eur J Heart Fail. 2002 Jun;4(3):353–359. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228–1233. Bostrom J, Caldwell J, McGuire K, Everson D. Telephone follow-up after discharge from the hospital: Does it make a difference? Appl Nurs Res. 1996;9:47–52. Braun E, Baidusi A, Alroy G, Azzam ZS. Telephone follow-up improves patients satisfaction following hospital discharge. Eur J Internal Med. 2009;20:221–225. Chan K, Lazarus M, Wingard R, et al. “Association between repeat hospitalization and early intervention in dialysis patients following hospital discharge.” Kidney International (2009) 76:331-41. Coleman E, Parry C, Chalmers S, et al. The care transitions intervention. Arch Internal Med. 2006;166:1822–1828. Creason H. Congestive heart failure telemanagement clinic. Lippencotts Case Management: Managing the Process of Patient Care. 2001 Jul-Aug;6(4):146-56. Dudas V, Bookwalter T, Kerr KM et al. The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine. 2001; 111(9B):26S-30S Dunn JM, Elliot TB, Lavy JA et al. Outpatient clinic review after arterial reconstruction: is it necessary? Annals of the Royal College of Surgeons of England. 1994 Sep;76(5):304-6. Jack B, Chetty V, Anthony D, et al. “A reengineered hospital discharge program to decrease rehospitalizaton.” Annals of Internal Medicine (2009) 150:178-88. Koehler BE, Richter KM, Youngblood L et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine. 2009 Apr;4(4):211-8. McDonald, MD. The hospitalist movement: wise or wishful thinking? Nurse management. 2001 Mar;32(3):30-1. Naylor M, Brooten D, Jones R et al. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine. 1994 Jun 15;120(12):999-1006. Parry C, Min SH, Chugh A et al. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly. 2009;28(2-3):84-99.

Measure Specifications

Summary of NQF Endorsement Review




American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-534)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

Measure Specifications

Summary of NQF Endorsement Review




Patient Safety and Adverse Events Composite (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-604)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

Measure Specifications

Summary of NQF Endorsement Review




Discharge to Community-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-523)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The ultimate goals of post-acute care are avoiding institutionalization and returning patients to their previous level of independence and functioning, with discharge to community being the primary goal for the majority of post-acute patients. For many, home is a symbol of independence, privacy, and competence. Discharge to community is considered a valuable outcome to measure because it is a multifaceted measure that captures the patient’s functional status, cognitive capacity, physical ability, and availability of social support at home. There is considerable variation in discharge to community rates within and across post-acute settings. Studies show geographic variation, variation across patient socioeconomic characteristics (for example, race and ethnicity), and variation by facility characteristics (for profit vs. nonprofit, freestanding vs. hospital-based, urban vs. rural). In the IRF setting, discharge to community rates vary across providers, ranging from about 60% to 75%. The 2015 MedPAC report shows that, in FY 2013, the facility-level, mean risk-adjusted discharge to community rate for IRFs within 100 days of admission was 75.8%, and the mean observed rate was 74.7%. Discharge to community rates also vary widely in the SNF setting, ranging from as low as 31% to as high as 65%. The 2015 MedPAC report shows a mean risk-adjusted discharge to community rate of 37.5% for SNFs within 100 days of admission, and mean observed rate of 40.1%. A multicenter study of 23 LTCHs reported that only 28.8% of 1,061 patients who were ventilator-dependent on admission were discharged to home or assisted living facility. A study of 66,510 Medicare beneficiaries during pre- and post-HH episodes, revealed that 64 percent of beneficiaries discharged from HH did not use any other Medicare-reimbursed acute or post-acute services in the 30 days following HH discharge. Significant numbers of patients were admitted to inpatient facilities (29 percent) and lesser numbers to skilled nursing facilities (7.6 percent), inpatient rehabilitation (1.5 percent) and home health (7.2 percent) or hospice (3.3 percent) within 30 days of HH discharge (Wolff et al., 2008).

Measure Specifications




Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-1127)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Medication review in post-acute care is generally considered to include medication reconciliation for all medications and medication review for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and medication review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

(New information provided by CMS on January 19, 2016) Medication review in post-acute care is generally considered to include medication reconciliation and drug regimen review for all medications and for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and drug regimen review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

Measure Specifications




Falls risk composite process measure (Program: Home Health Quality Reporting Program; MUC ID: MUC15-207)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
See literature review for NQF #0537 about the importance of assessing falls among home health patients and developing interventions.

Measure Specifications




Improvement in Dyspnea in Patients with a Primary Diagnosis of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and/or Asthma (Program: Home Health Quality Reporting Program; MUC ID: MUC15-235)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
See literature for NQF measure #0179 about the importance of dyspnea and the potential for home health to affect outcomes.

Measure Specifications




Medicare Spending Per Beneficiary-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-1134)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Medicare payments to PAC have grown at a consistently higher rate than other major Medicare sectors. Between 2001 and 2013, Medicare PAC spending grew at an annual rate of 6.1 percent and doubled to $59.4 billion.

Measure Specifications




Potentially Preventable 30-Day Post-Discharge Readmission Measure for Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-234)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
This is the environmental scan conducted that demonstrates potentially preventable readmissions is a concern for community dwelling individuals and that home health interventions can reduce the risk of readmission.

Measure Specifications




Adult Local Current Smoking Prevalence (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1013)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Tobacco use and exposure to secondhand smoke caused more than 400,000 in the U.S. in each year between 2000 and 2004, according to the CDC. These deaths represent more than 5 million years of potential life lost (YPLL).1 At the state level, the median annual number of lives lost per state was 5,534, though there was a great deal of variation by state.2 National Cost of Tobacco Use The Centers for Disease Control and Prevention (CDC) estimates that, in the U.S. in each year from 2001 through 2004, an average of $96 billion was spent on health care due to smoking.1 A 2007 study calculates the cost of smoking to the U.S. Medicaid system, concluding that the projected lifetime costs of smoking to Medicaid, for a single cohort—current 24-year-old smokers—is nearly $1 billion. 1. Centers for Disease Control and Prevention (CDC). Smoking attributable mortality, years of potential life lost, and productivity losses--United States, 2000-2004. MMWR Morb Mortal Wkly Rep. 2008 Nov 14;57(45):1226-8. 2. Centers for Disease Control and Prevention (CDC). State-specific smoking-attributable mortality and years of potential life lost--United States, 2000-2004. MMWR Morb Mortal Wkly Rep. 2009 Jan 23;58(2):29-33. Erratum in: MMWR Morb Mortal Wkly Rep. 2009 Feb 6;58(4):91. 3. Trogdon J, Pais J. Saving Lives, Saving Money II: Tobacco-Free States Spend Less on Medicaid. A Policy Report of the American Legacy Foundation. 2007. 4. Centers for Disease Control and

Measure Specifications

Summary of NQF Endorsement Review




American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-534)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

Measure Specifications

Summary of NQF Endorsement Review




Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-835)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

Measure Specifications




Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-836)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

Measure Specifications




Excess Days in Acute Care after Hospitalization for Pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-391)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pneumonia results in approximately 1.2 million hospital admissions each year and accounts for more than $10 billion annually in hospital expenditures. 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. 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. 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). Rising rates of observation stays among Medicare beneficiaries have gained the attention of patients, providers, and policymakers (Feng et al., 2012; Rising et al., 2013; Vashi et al., 2013). A report from the Office of the Inspector General (OIG) notes the potential relationship between hospital use of observation stays as an alternative to short-stay inpatient hospitalizations as a response to changing hospital payment incentives (Wright, 2013). Thus, in the context of the publicly reported CMS 30-day readmission measures, the increasing use of ED visits and observation stays has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post-discharge period. References: Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care. Oct 1997;35(10):1044-1059. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Archives of Internal Medicine. Apr 24 2000;160(8):1074-1081. Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. Apr 1992;27(1):81-101. Courtney EDJ, Ankrett S, McCollum PT. 28-Day emergency surgical re-admission rates as a clinical indicator of performance. Ann R Coll Surg Engl. Mar 2003;85(2):75-78. Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006;130(3):794-799 Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health affairs (Project Hope). Jun 2012;31(6):1251-1259. Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. Jun 1991;90(6):667-674. Halfon P, Eggli Y, Pr, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Medical Care. Nov 2006;44(11):972-981. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. Journal of General Internal Medicine. 1996;11(10):597-607. Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine. Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364-371. Wright S. Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. Washington, DC: OIG;2013

Measure Specifications




Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-294)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates.

Measure Specifications




Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-378)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary[1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals 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 to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with pneumonia both during hospitalization and immediately post-discharge. Pneumonia is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

Measure Specifications

Summary of NQF Endorsement Review




Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1135)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates. The hybrid measure addresses a limitation of the claims-only measure by incorporating clinical data collected at the time of admission to assess the condition of the patient before care has been administered.

Measure Specifications




Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1033)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates. The hybrid measure addresses a limitation of the claims-only measure by incorporating clinical data collected at the time of admission to assess the condition of the patient before care has been administered.

Measure Specifications




INR Monitoring for Individuals on Warfarin after Hospital Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1015)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
An analysis of the Food and Drug Administration’s (FDA) Adverse Drug Event Reporting System found that warfarin ranked seventh overall in drugs identified to cause death, disability, or other serious adverse outcomes (Moore, Cohen, & Furberg, 2007). Evidence suggests that low INR (INR < 2) is associated with an increased risk of stroke and high INR (INR > 3) is associated with increased risk of bleeding (Reynolds, 2004). A study by White et al. (2007) found that patients with poor INR control suffered higher rates of mortality and major bleeding when compared to those with good or moderate INR control. Patients in the transition period from hospital to home are at particular risk for adverse events from medication errors in general, and for warfarin in particular, as they move from a tightly controlled environment to one with limited supervision and support (Forster et al., 2005). A timely INR test shortly after hospital discharge is expected to lead to the stabilization of the patient’s warfarin regimen and avoidance of non-therapeutic INR levels and, therefore, result in fewer warfarin-related bleeding, thromboembolic events, and lower mortality. The 2012 American College of Chest Physicians guidelines for antithrombotic therapy and prevention of thrombosis recommend INR monitoring within 1-2 weeks for patients with a sub-therapeutic or supra-therapeutic INR (Holbrook et al., 2012). Three recent studies have been published on INR monitoring after hospital discharge and/or INR monitoring after an out-of-range value. In a population-based sample of Canadian patients on warfarin (Van Walraven et al., 2007), hospitalization was associated with less time in the therapeutic range, more time with INR <1.5, and more time with INR >=5.0. Qualls et al. (2013) compared patients with heart failure with and without at least one INR test within 45 days of discharge and found that those who had been tested had lower risks of mortality and myocardial infarction one year after discharge. Finally, in a study of patients in VA anticoagulation clinics (Rose et al., 2011), longer follow-up intervals for repeat tests after both INR values above and below the therapeutic range were found to be associated with worse control of anticoagulation among ambulatory patients at the clinic level. Food and Drug Administration. (2011). Warfarin (Coumadin) product labeling. Reference ID 3022954. Retrieved Oct. 16, 2013, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/009218s107lbl.pdf Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2005). Adverse drug events occurring following hospital discharge. Journal of General Internal Medicine, 20(4), 317–323. Holbrook, A., Schulman, S., Witt, D. M., Vandvik, P. O., Fish, J., Kovacs, M. J., ... & Guyatt, G. H. (2012). Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST Journal, 141(2_suppl), e152S-e184S. Moore, T. J., Cohen, M. R., & Furberg, C. D. (2007). Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Archives of Internal Medicine, 167(16), 1752-1759. Qualls, L. G., Greiner, M. A., Eapen, Z. J., Fonarow, G. C., Mills, R. M., Klaskala, W., . . . Curtis, L. H. (2013). Postdischarge international normalized ratio testing and long-term clinical outcomes of patients with heart failure receiving warfarin: Findings from the ADHERE registry linked to Medicare claims. Clinical Cardiology, 36(12), 757-765. Reynolds, M. W., Fahrbach, K., Hauch, O., Wygant, G., Estok, R., Cella, C., & Nalysnyk, L. (2004). Warfarin anticoagulation and outcomes in patients with atrial fibrillation: a systematic review and metaanalysis. CHEST Journal, 126(6), 1938-1945. Rose, A. J., Ozonoff, A., Henault, L. E., & Hylek, E. M. (2008). Warfarin for atrial fibrillation in community-based practise. Journal of Thrombosis and Haemostasis, 6(10), 1647-1654. Van Walraven, C., Austin, P. C., Oake, N., Wells, P., Mamdani, M., Forster, A. J. (2007). The effect of hospitalization on oral anticoagulation control: A population-based study. Thrombosis Research 119(6), 705–714. White, H. D., M. Gruber, Feyzi, J., Kaatz, S., Tse, H. F., Husted, S., et al. (2007). Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: results from SPORTIF III and V. Archives of Internal Medicine, 167(3), 239-245.

Measure Specifications

Summary of NQF Endorsement Review




IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1083)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The evidence supporting VBAC is robust and well-summarized in the ACOG and AAFP guidelines.

Measure Specifications




National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-531)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Numerous individual studies and systematic reviews provide strong evidence that measurement of antimicrobial use and data-driven interventions by antimicrobial stewardship programs (ASPs) lead to more judicious use of antibiotics, reduced antimicrobial resistance, and other favorable healthcare outcomes (Feazel 2014; Davey 2006; Davey 2013; Kaki 2011). Antimicrobial use measurement enables ASPs to understand prescribing practices, focus efforts on improvement, and determine the impact of their activities (Pollack, 2014). Although standardized metrics have been developed to measure antibiotic use, differences in measurement, limited uptake, and variation among facilities has impeded the ability to compare antibiotic use among hospitals. The measure will serve as a quantitative guide for hospital and health system ASPs, enabling them to benchmark antibiotic use in their facilities and patient care locations against nationally aggregated data. The measure focuses on antibiotic agents that have been shown to be high value targets for antimicrobial stewardship programs activities such as protocols for use or post-prescription reviews to determine need for de-escalation, dose-optimization or oral conversion. Knowledge about antibiotic use patterns of these agents is a primary means to prioritize and evaluate antimicrobial stewardship efforts.

Measure Specifications




Patient Safety and Adverse Events Composite (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-604)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

Measure Specifications

Summary of NQF Endorsement Review




Spinal Fusion Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-837)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

Measure Specifications




Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-838)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., .Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

Measure Specifications




Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-951)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Cancer patients receiving chemotherapy have much higher rates of admissions and ED use than other patients. A study of 2007 commercial claims data for more than 14 million patients found that cancer patients average one admission per year; 40 percent of those admissions were chemotherapy related (Kolodziej et al. 2011). The authors also found that cancer patients average approximately two ED visits per year, about half of which were chemotherapy related. Common complications of chemotherapy treatment include nausea, emesis, anemia, neutropenic fever, diarrhea, dehydration, and pain (Burton et al. 2007; Crawford et al. 2004; Groopman and Itri 2000; Osoba et al. 1997; Richardson and Dobish 2007; Stein et al. 2010). Chemotherapy-related admissions and ED visits may be due to outpatient chemotherapy patients having unmet needs and gaps in care, which, if addressed, could reduce admissions and ED visits and increase patients’ quality of life (Hassett et al. 2006; Mayer et al. 2011; McKenzie et al. 2011). Although it is extremely unlikely that all admissions and ED visits related to chemotherapy can be avoided by prevention and treatment of side effects and complications, there is evidence and consensus among providers on ways to prevent and treat each of the symptoms included in the numerator of this measure. Measurement of admissions and ED visits for patients receiving outpatient chemotherapy should encourage reporting facilities to take steps to prevent and improve management of side effects and complications from treatment. Poor performance on the measure would reflect high resource use and significant consequences for patient/society due to poor quality; admissions and ED visits are costly to payers and reduce quality of life for patients. Burton, A.W., G.J. Fanciullo, R.D. Beasley, and M.J. Fisch. “Chronic Pain in the Cancer Survivor: A New Frontier”. Pain Medicine, vol. 8, 2007, pp. 189–198. Crawford, J.C., D.C. Dale, and G.H. Lyman. “Chemotherapy-Induced Neutropenia.” Cancer, vol. 15, 2004, pp. 228–237. Groopman, J.E., and L.M. Itri. “Chemotherapy-Induced Anemia in Adults: Incidence and Treatment.” Journal of the National Cancer Institute, vol. 91, 2000, pp. 1616–1634. Hassett, M.J., J. O’Malley, J.R. Pakes, J.P. Newhouse, and C.C. Earle. “Frequency and Cost of Chemotherapy-Related Serious Adverse Effects in a Population Sample of Women with Breast Cancer.” Journal of the National Cancer Institute, vol. 98, no. 16, 2006, pp. 1108–1117. Kolodziej, M., J.R. Hoverman, J.S. Garey, J. Espirito, S. Sheth, A. Ginsburg, M.A. Neubauer, D. Patt, B. Brooks, C. White, M. Sitarik, R. Anderson, and R. Beveridge. “Benchmarks for Value in Cancer Care: An Analysis of a Large Commercial Population.” Journal of Oncology Practice, vol. 7, 2011, pp. 301–306. Mayer, D.K., D. Travers, A. Wyss, A. Leak, A. Waller. “Why Do Patients with Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina.” Journal of Clinical Oncology, vol. 26, no. 19, 2011, pp. 2683–2688. McKenzie, H., L. Hayes, K. White, K. Cox, J. Fethney, M. Boughton, and J. Dunn. “Chemotherapy Outpatients’ Unplanned Presentations to Hospital: A Retrospective Study.” Support Care Cancer, vol. 19, 2011, pp. 963–969. Osoba, D., B. Zee, D. Warr, J. Latreilee, L. Kaizer, and J. Pater. “Effect of Postchemotherapy Nausea and Vomiting on Health-Related Quality of Life.” Support Care Cancer, vol. 5, 1997, pp. 307–313. Richardson, G., and R. Dobish. “Chemotherapy Induced Diarrhea.” Journal of Oncology Pharmacy Practice, vol. 13, no.4, 2007, pp. 181–98. Stein, A., W. Voigt, and K. Jordan. “Chemotherapy-Induced Diarrhea: Pathophysiology, Frequency, and Guideline-Based Management.” Therapeutic Advances Medical Oncology, vol. 2, 2010, pp. 51–63.

Measure Specifications




Risk-standardized hospital visits within 7 days after hospital outpatient surgery (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-982)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nearly 70% of all surgeries in the US are now performed in the outpatient setting with most performed as same-day surgeries at HOPDs.[1] While most outpatient surgery is safe, there are well-described and potentially preventable adverse events that occur after outpatient surgery, such as uncontrolled pain, urinary retention, infection, bleeding, and venous thromboembolism, which can result in unanticipated hospital visits. Similarly, direct admissions after surgery that are primarily caused by non-clinical patient considerations, such as lack of transport home upon discharge, or hospital logical issues, such as delayed start of surgery, are common causes of unanticipated yet preventable hospital admissions following same-day surgery. Hospital utilization following same-day surgery is an important and accepted patient-centered outcome reported in the literature. National estimates of hospital visit rates following surgery vary from 0.5-9.0% based on the type of surgery, outcome measured (admissions alone or admissions and emergency department [ED] visits), and timeframe for measurement after surgery.[2-9] Furthermore, hospital visit rates vary among HOPDs,[7] suggesting variation in surgical and discharge care quality. However, providers (HOPDs and surgeons) are often unaware of their patients’ hospital visits after surgery since patients often present to the ED or to different hospitals.[10] Therefore, a quality measure of hospital visits following outpatient same-day surgery can improve transparency, inform patients and providers, and foster quality improvement. The literature suggests 1.3-13.6% of outpatient surgeries at HOPDs result in an inpatient admission with the admission rate varying by type of surgery and HOPD case mix.[3,7-9,11-21] Of these admissions, 40-60% are reported to be due to adverse effects of the surgery, anesthesia, or due to other suspected medical problems such as chest pain.[3,7-9,11-21] A smaller proportion of admissions are due to non-clinical reasons such as lack of transport home or logistical issues such as delayed start of surgery.[3,7-9,11-19] When specifically assessed, up to 40% of direct admissions after outpatient surgery have been found to be preventable.[19] Major and minor adverse events, such as uncontrolled pain, urinary retention, infection, bleeding, and venous thromboembolism, are well documented to occur post-discharge and result in unanticipated hospital visits.[12,13,22] Some hospital visits post-discharge are for scheduled follow-up care provided after surgery (e.g., visits for rehabilitation). We remove these ‘planned’ hospital visits from the outcome. We limit the outcome of hospital visits to 7 days since existing literature suggests the vast majority of adverse events after surgery occur within the first 7 days following the surgery.[4,12] We observed in our own data the highest rates of hospital visits occurring within 7 days of surgery. References: 1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. National health statistics reports. Jan 28 2009(11):1-25. 2. Majholm B, Engbaek J, Bartholdy J, et al. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta anaesthesiologica Scandinavica. Mar 2012;56(3):323-331. 3. Linares-Gil MJ, Pelegri-Isanta MD, Pi-Siqués F, Amat-Rafols S, Esteva-Ollé MT, Gomar C. Unanticipated admissions following ambulatory surgery. Ambulatory Surgery. 12// 1997;5(4):183-188. 4. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Archives of surgery (Chicago, Ill. : 1960). Jan 2004;139(1):67-72. 5. Coley KC, Williams BA, DaPos SV, Chen C, Smith RB. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. Journal of clinical anesthesia. Aug 2002;14(5):349-353. 6. Hollingsworth JM, Saigal CS, Lai JC, Dunn RL, Strope SA, Hollenbeck BK. Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. The Journal of urology. Oct 2012;188(4):1274-1278. 7. Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Quality in health care : QHC. Jun 1999;8(2):86-91. 8. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery--a prospective study. Canadian journal of anaesthesia = Journal canadien d'anesthesie. Jul 1998;45(7):612-619. 9. Aldwinckle RJ, Montgomery JE. Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery. Anaesthesia. Jan 2004;59(1):57-59. 10. Mezei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Annals of surgery. Nov 1999;230(5):721-727. 11. Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality assurance. The Australian and New Zealand journal of surgery. Mar 2000;70(3):216-220. 12. Mattila K, Toivonen J, Janhunen L, Rosenberg PH, Hynynen M. Postdischarge symptoms after ambulatory surgery: first-week incidence, intensity, and risk factors. Anesthesia and analgesia. Dec 2005;101(6):1643-1650. 13. Minatti WR, Flavio B, Pablo C, Raúl R, Guillermo P, Miguel S. Postdischarge unplanned admission in ambulatory surgery—a prospective study. Ambulatory Surgery. 1// 2006;12(3):107-112. 14. Morales R, Esteve N, Casas I, Blanco C. Why are ambulatory surgical patients admitted to hospital?: Prospective study. Ambulatory Surgery. 3/15/ 2002;9(4):197-205. 15. Ogg T, Hitchock M, Penn S. Day surgery admissions and complications. Ambulatory Surgery. 1998;6:101-106. 16. Mingus ML, Bodian CA, Bradford CN, Eisenkraft JB. Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients. Journal of clinical anesthesia. Sep 1997;9(6):446-450. 17. Laeeque R, Samad A, Raja AJ. Day care surgery at a university hospital--who is responsible after discharge. JPMA. The Journal of the Pakistan Medical Association. Dec 2001;51(12):422-427. 18. Crew JP, Turner KJ, Millar J, Cranston DW. Is day case surgery in urology associated with high admission rates? Annals of the Royal College of Surgeons of England. Nov 1997;79(6):416-419. 19. Awan FN, Zulkifli MS, McCormack O, et al. Factors involved in unplanned admissions from general surgical day-care in a modern protected facility. Irish medical journal. May 2013;106(5):153-154. 20. Rudkin GE, Bacon AK, Burrow B, et al. Review of efficiencies and patient satisfaction in Australian and New Zealand day surgery units: a pilot study. Anaesthesia and intensive care. Feb 1996;24(1):74-78. 21. Paez A, Redondo E, Linares A, Rios E, Vallejo J, Sanchez-Castilla M. Adverse events and readmissions after day-case urological surgery. International braz j urol : official journal of the Brazilian Society of Urology. May-Jun 2007;33(3):330-338. 22. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesthesia and analgesia. Feb 1997;84(2):319-324.

Measure Specifications

Summary of NQF Endorsement Review

Developer response:

Committee Response:



  • Endorsement Committee Recommendation: Standing Committee Recommendation for Endorsement: Y-18; N-1




    • Hospice and Palliative Care Composite Process Measure (Program: Hospice Quality Reporting Program; MUC ID: MUC15-231)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Treatment Preferences and Spiritual Care The Hospice and Palliative Care - Treatment Preferences measure addresses patient autonomy for patients with high severity of illness and risk of death, including seriously and incurably ill patients enrolled in hospice or hospital-based palliative care. 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. The affected populations are large; in 2009, 1.56 million people with life-limiting illness received hospice care.(NHPCO 2010) 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.(Center to Advance Palliative Care 2010) Patients and family caregivers rate control over treatment decisions as a high priority when living with serious and life-limiting illnesses. (Singer et al 1999) From a recent systematic review of clinical trials, moderate evidence supports multicomponent interventions to increase advance directives, and "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.( Lorenz et al 2008) 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.(Wright et al 2010; 2008) Spiritual care also has been shown to be a critical element of quality of life at the end of life.(Boston et al 2011; Cohen et al 1996; Puchalski et al 2009; Steinhauser et al 2000) References Boston P, Bruce A, Schrieber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage. 2011 Mar;41(3):604-18. Epub 2010 Dec 8. Center to Advance Palliative Care http://www.capc.org/news-and-events/releases/04-05-10 Cohen SR, Mount BM, Tomas JJN, Mount LF. Existential well-being is an important determinant of quality of life. Cancer 1996; 77:576-86. 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. NHPCO Facts and figures: hospice care in America 2010 edition http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf Puchalski C, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, Chochinov H, Handzo G, Nelson-Becker H, Prince-Paul M, Pugliese K, Sulmasy D. Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference. J Palliat Med. 2009 Oct;12(10):885-904. Review. Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients´ perspective. JAMA 1999; 281: 163-168. Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000 Nov 15;284(19):2476-82. 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. 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. Pain Research on care of patients with serious incurable illness and those nearing the end of life shows they experience high rates of pain (40-70% prevalence) and other physical, emotional, and spiritual causes of distress. (SUPPORT, 1995; Gade et al 2008) 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 access to effective treatment for symptoms such as pain and shortness of breath. The affected populations are large; in 2009, 1.56 million people with life-limiting illness received hospice care. (NHPCO, 2010) 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.(Center to Advance Palliative Care 2010) Patients and family caregivers rate pain management as a high priority when living with serious and life-limiting illnesses. (Singer, 1999) The consequences of inadequate screening, assessment and treatment for pain include physical suffering, functional limitation, and development of apathy and depression. (Gordon 2005) References: Center to Advance Palliative Care http://www.capc.org/news-and-events/releases/04-05-10 Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180–190. Gordon DB, Dahl JL, Miaskowski C et al. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574-1580. NHPCO Facts and figures: hospice care in America 2010 edition http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients´ perspective. JAMA 1999; 281: 163-168. The Writing Group for the SUPPORT Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognosis and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274:1591-1598. http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=608 Shortness of Breath Dyspnea is a common symptom in serious illness, more common than pain for patients with chronic obstructive lung disease, lung cancer, cystic fibrosis, and restrictive lung diseases such as pulmonary fibrosis.(Luce et al 2001) Unlike pain, dyspnea severity is associated with the risk of death.(Olajidae et al 2007) Between 50-70% of patients with advanced lung cancer experience dyspnea near the end of life. As detailed in a recent systematic review, opioids, oxygen and non-pharmacologic nursing interventions demonstrate efficacy in randomized controlled trials of treatment for dyspnea in cancer and in other serious illness.( Ben-Aharon et al 2008; Lorenz et al 2008) Unfortunately, dyspnea is often persistent and under-treated in advanced cancer and other end-stage diseases.( Roberts et al 1993 ) References: Ben-Aharon I, Gafter-Gvili A, Paul M et al. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008; 26:2396-2404. 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. Luce JM, Luce JA. Management of dyspnea in patients with far-advanced lung disease. JAMA 2001; 285:1331-1337. Olajidae O, Hanson LC, Usher BM et al. Validation of the Palliative Performance Score in the acute tertiary hospital setting. J Palliat Med 2007; 10:111-117 Roberts DK, Thorne SE, Pearson C. Cancer Nurs 1993; 16:310-320 Bowel Regimen Opioids are commonly used in the management of moderate to severe pain, and constipation is a common adverse effect. (Myotoku 2010; Tuteja 2010; Pappagallo 2001) A systematic review evaluating the extent and management of opioid-related side effects in both cancer and non-cancer patients indicated that tolerance is not developed to opioid-induced constipation and confirmed the need for prophylaxis. (McNicol 2003) Risk of constipation is further aggravated by immobility and dehydration in older people with pain. The American Pain Society and American Geriatrics Society as well as expert consensus opinion recognize the frequency of constipation with opioid use and the necessity for prophylactic therapy. (APS 2005; RANO 2002; AGS 2002; APS 2002; Weiner 2001; Davis 2003; Etzioni 2007; Dy 2008) A study of 194,017 emergency department visits made by 76,759 cancer patients in the final 6 months of life revealed that 3,392 visits were made for constipation. (Barbera 2010) A Cochrane systematic review of 26 studies of patients at least 18 years old taking opioids for at least 6 months for non-cancer pain revealed gastrointestinal complaints (e.g., constipation, nausea, dyspepsia) as the most commonly reported side effect. (Noble 2010) References: AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(6 Suppl):S205-24 American Pain Society (APS). Guideline for the management of cancer pain in adults and children. 2005 American Pain Society (APS). Guideline of the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. 2002. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? Can Med Assoc J 2010;182(6):563-569 Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly. Drugs Aging 2003;20(1):23-57 Dy SM, Asch SM, Naeim A, et al. Evidence-based standards for cancer pain. J Clin Oncol 2008;26(23):3879-3885 Etzioni S, Chodosh J, Ferrell BA, et al. Quality indicators for pain management in vulnerable elders. JAGS 2007;55:S403-S408 McNicol E, Horowicz-Mehler N, Fisk RA et al. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain 2003;4(5):231-56 Myotoku M, Nakanishi A, Kanematsu M, et al. Reduction in opioid side effects by prophylactic measures of palliative care team may result in improved quality of life. J Pall Care 2010;13(4):401-406 Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid treatment for chronic noncancer pain. Cochrane Database Sys Rev 2010;(1):CD006605 Pappagallo M. Incidence, prevalence, and management of opioid bowel dysfunction. Am J Surg 2001;182(5A Suppl):11s-8s Registered Nurses Association of Ontario (RNAO). Assessment and management of pain. 2002. (Nursing Best Practice Guideline: Shaping the Future of Nursing) Tuteja AK, Biskupiak J, Stoddard GJ, et al. Opioid-induced bowel disorders and narcotic bowel syndrome in patients with chronic non-cancer pain. Neurogastroenterol Motil 2010;22:424-e96 Weiner DK, Hanlon JT. Pain in nursing home residents: management strategies. Drugs Aging 2001;18(1):13-29

    Measure Specifications




    Hospice Visits When Death Is Imminent (Program: Hospice Quality Reporting Program; MUC ID: MUC15-227)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The literature supports hospice visits when death is imminent as a high priority in end-of-life care by showing the last week of life as the point in the terminal illness trajectory with the highest symptom burden. Particularly during the last few days before death, patients experience myriad physical and emotional symptoms, necessitating close care and attention from the integrated hospice team. Physical symptoms with high prevalence in the last week of life include fatigue, pain, dyspnea, respiratory secretions/death rattle, anorexia, dry mouth, nausea and/or vomiting, affecting a quarter to more than 80 percent of imminently dying patients. The specific prevalence of each symptom varies across studies, reflecting the heterogeneity of the samples and the range of assessment techniques used.(Lynn, Teno et al. 1997, Klinkenberg, Willems et al. 2004, Kehl and Kowalkowski 2012) Psychosocial symptoms with high prevalence in the last week of life include confusion, anxiety, depression and delirium, affecting a third to more than half of imminently dying patients.(Klinkenberg, Willems et al. 2004) A study of after-death interviews with close relatives of terminal patients found that 75 percent of patients experienced at least two symptoms requiring management in the last week of life.(Klinkenberg, Willems et al. 2004) The symptom burden typically increases significantly in the last few days of life compared to the previous stage,(Currow, Smith et al. 2010) further supporting care of the imminently dying patient as a high priority aspect of healthcare. Studies focusing on the expectations of patients and families also demonstrate the importance of care and attention from the hospice team in the days leading up to death. Caregivers of dying patients agree overwhelmingly with the importance of preparation at the end of life. Hospice assistance, ranging from legal to logistical to emotional, is paramount in preparing hospice patients and their families for imminent death. (Steinhauser, Christakis et al. 2000) Bereaved family members and friends from a variety of settings identified the provision of physical comfort and emotional support to dying patients and their families as fundamental aspects of high-quality care.(Steinhauser, Christakis et al. 2000) References: Currow, D.C., et al., Do the Trajectories of Dyspnea Differ in Prevalence and Intensity By Diagnosis at the End of Life? A Consecutive Cohort Study. Journal of Pain and Symptom Management, 2010. 39(4): p. 680-690. Kehl, K.A. and J.A. Kowalkowski, A Systematic Review of the Prevalence of Signs of Impending Death and Symptoms in the Last 2 Weeks of Life. American Journal of Hospice & Palliative Medicine, 2012. 30(6): p. 601-616. Klinkenberg, M., et al., Symptom Burden in the Last Week of Life. J Pain Symptom Manage., 2004. 27(1): p. 5-13. Lynn, J., et al., Perceptions by Family Members of the Dying Experience of Older and Seriously Ill Patients. Annals of Internal Medicine, 1997. 126(2): p. 97-106. Steinhauser, K.E., et al., Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. JAMA, 2000. 284(19): p. 2476-2482.

    Measure Specifications




    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-534)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

    Measure Specifications

    Summary of NQF Endorsement Review




    Cellulitis Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1143)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

    Measure Specifications




    Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1144)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

    Measure Specifications




    Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-395)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    It is envisioned that this measure will provide hospitals with procedure-specific information to help improve patient safety and quality of care, thus reducing mortality rates. CABG is a priority area for outcomes measure development because it is a common procedure associated with considerable morbidity, mortality, and health care spending. In 2007, there were 114,028 hospitalizations for CABG surgery and 137,721 hospitalizations for combined surgeries for CABG and valve procedures (“CABG plus valve” surgeries) among Medicare FFS patients in the U.S. [1] CABG surgeries are costly procedures that account for the majority of major cardiac surgeries performed nationally. In fiscal year 2009, isolated CABG surgeries accounted for almost half (47.6%) of all cardiac surgery hospital admissions in Massachusetts. [2] In 2008, the average Medicare payment was $30,546 for CABG without valve and $47,669 for CABG plus valve surgeries. [3] Mortality rates following CABG surgery vary widely across hospitals. Our mean RSMR is 3.2% with a range from 1.5%-7.9%. The median risk-standardized rate is 3.0% (25th and 75th percentiles are 2.6% and 3.6%, respectively). Similarly, published data also demonstrate variation in mortality rates. 1. Drye E, Krumholz H, Vellanky S, Wang Y. Probing New Conditions and Procedures for New Measure Development: Yale New Haven Health Systems Corporation; Center for Outcomes Research and Evaluation.; 2009:1-7. 2. Massachusetts Data Analysis Center. Adult Coronary Artery Bypass Graft Surgery in the Commonwealth of Massachusetts: Hospital and Surgeons Risk-Standardized 30-Day Mortality Rates. In: Health MDoP, ed. Boston2009:77. 3. Pennsylvania Health Care Cost Containment Council. Cardiac Surgery in Pennsylvania 2008-2009. Harrisburg2011:60. 4. American New York State Department of Health. Adult Cardiac Surgery in New York State 2006-20082010:54.

    Measure Specifications

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-378)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary[1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals 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 to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with pneumonia both during hospitalization and immediately post-discharge. Pneumonia is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

    Measure Specifications

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-369)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    In 2012 total Medicare expenditures were $574.2 billion, representing 3.6% of gross domestic product (GDP). Current estimates suggest that Medicare spending will increase to 5.6% of GDP by 2035 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary [1]. The growth in Medicare spending is unsustainable and highlights the need to create incentives for high value care. A critical first step in moving toward high value care is to define an approach to calculate costs that is transparent to consumers and fair to providers. 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. 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. References: 1. Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2013 Annual Report, May 31, 2013. 2. Andrews RM, Elixhauser, A. The National Hospital Bill: Growth Trends and 2005 Update on the Most Expensive Conditions by Payer. Agency for Healthcare Research and Quality. 2007.

    Measure Specifications

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-322)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary [1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals 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 to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with heart failure both during hospitalization and immediately post-discharge. Heart failure is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

    Measure Specifications

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-295)

    Summary of Workgroup Deliberations

    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. 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. [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 study of the costs of hip and knee replacement surgery. Med Care. 2009;47(7):732-741. 6. Suter LG, et al., Medicare Hospital Quality Chartbook 2013: Performance Report on Outcome Measures, 2013. 7. Birkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS. Hospital quality and the cost of inpatient surgery in the United States. Annals of surgery. 2012;255(1):1-5. 8. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatient surgery. JAMA surgery. Jun 2013;148(6):549-554. 9. CMS. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. http:/ / innovation.cms.gov/initiatives/bundled?payments/ [accessed Jan 7, 2014] 10. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatient surgery. JAMA surgery. Jun 2013;148(6):549-554.

    Measure Specifications




    Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1145)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf

    Measure Specifications




    Patient Safety and Adverse Events Composite (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-604)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

    Measure Specifications

    Summary of NQF Endorsement Review




    Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1065)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    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 (McGlynn 2003, Gentilello 2005). Currently, less than one in twenty patients with an addiction is referred for treatment (Gentilello 1999). Unfortunately, many physicians mistakenly believe that substance use problems are largely confined to the young. They are significantly less likely to recognize an alcohol problem in an older patient than in a younger one. (Curtis 1989) As a result, these problems usually go undetected, resulting in harmful, expensive, and sometimes even catastrophic consequences. This is demonstrated by the fact that few older adults who need substance use treatment actually receive it. In 2005, persons 65 years and older made up only 11,344 out of 1.8 million substance use treatment episodes recorded.(SAMHSA 2007) Citations: • Gentilello LM, Ebel BE, Wickizer TM, Salkever DS Rivera FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Ann Surg. 2005 Apr;241(4):541-50. • Gentilello LM, Villaveces A, Ries RR, Nason KS, Daranciang E, Donovan DM Copass M, Jurkovich GJ Rivara FP. Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma. 1999 Dec;47(6):1131-5; discussion 1135-9. • McGlynn, EA, Asch SM, Adams J, Keesey J, et al. The New England Journal of Medicine. Boston: Jun 26, 2003. Vol. 348, Iss.26; pg. 2635, 11pgs. • Curtis, J.R.; Geller, G.; Stokes, E.J. ; et al. Characteristics, diagnosis, and treatment of alcoholism in elderly patients. J Am Geriatr Soc 37:310-316, 1989. • SAMHSA. Office of Applied Studies. Older adults in substance abuse treatment: 2005. The DASIS Report. Rockville MD, November 8, 2007.

    Measure Specifications

    Summary of NQF Endorsement Review




    Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1082)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Patient Volume Analysis of calendar year 2013 IPF claims data showed that 308,915 Medicare beneficiaries had 471,349 IPF stays. This group of patients is particularly vulnerable. Sixty-six percent of discharges are for patients under 65 indicating Medicare eligibility due to disability; 56% of discharges also have dual eligibility with Medicaid indicating they have limited financial resources. Twenty-nine percent of Medicare beneficiaries who used IPF services in 2013 had more than one stay. For CY 2012 and CY 2013, approximately one-third of all admissions for a principal psychiatric disorder (ICD-9 codes 290-319) were to short-stay acute care hospitals (including critical access hospitals). However, of the 1669 short-stay acute care hospitals with psychiatric admissions, only 39% had 25 or more psychiatric admissions. Forty percent of the psychiatric admissions to short-stay acute care hospitals were to hospitals that also had IPF units. The HWR measure for short-stay acute care hospitals includes some of these diagnoses (i.e., dementia, substance use, and screening/history of mental health and substance use). Consequences of Readmissions Readmission is considered an adverse event because it indicates deterioration in health status after discharge from the IPF that requires an acute level of care. In addition to patient burden, readmissions impacts cost. A MedPAC report indicated that Medicare payments to IPFs averaged nearly $10,000 per discharge (MedPAC, 2014) MedPAC analyses also showed that spending for Medicare beneficiaries who use IPF services is substantially higher than for all fee-for-service beneficiaries, due in part to the IPF stays (MedPAC, 2010). Performance Variation There is variation in 30-day all-cause readmission rates across IPFs, which is noted in Item 44: Evidence of performance gap. Evidence of Effective Interventions to Reduce Readmissions Some individual studies and systematic reviews have supported the positive effect of the following interventions in reducing psychiatric readmissions: • Follow-up within 7 days of discharge (Mark, 2013) • Stabilizing condition prior to discharge (Durbin, 2007) • Transition/discharge practices (Vigod, 2013; Steffen, 2009) • Intensive case management (Dieterich, 2010) Citations: *Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. The Cochrane database of systematic reviews. 2010(10):Cd007906. *Durbin J, Lin E, Layne C, Teed M. Is readmission a valid indicator of the quality of inpatient psychiatric care? J. Behav. Health Serv. Res. 2007;34(2):137-150. *Mark T, Tomic KS, Kowlessar N, Chu BC, Vandivort-Warren R, Smith S. Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder. J. Behav. Health Serv. Res. 2013;40(2):207-221. *MedPAC. Chapter 6: Inpatient Psychiatric Care in Medicare: Trends and Issues. June 2010 Report to Congress: Aligning Incentives in Medicare. Washington, DC: MedPAC; 2010:161-187. * MedPAC. Inpatient Psychiatric Facility Services Payment System. Washington, DC: MedPAC; October 2014. *Steffen S, Kosters M, Becker T, Puschner B. Discharge planning in mental health care: a systematic review of the recent literature. Acta Psychiatr. Scand. 2009;120(1):1-9. *Vigod SN, Kurdyak PA, Dennis CL, et al. Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. Br. J. Psychiatry. 2013;202(3):187-194.

    Measure Specifications




    Discharge to Community-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-408)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The ultimate goals of post-acute care are avoiding institutionalization and returning patients to their previous level of independence and functioning, with discharge to community being the primary goal for the majority of post-acute patients. For many, home is a symbol of independence, privacy, and competence. Discharge to community is considered a valuable outcome to measure because it is a multifaceted measure that captures the patient’s functional status, cognitive capacity, physical ability, and availability of social support at home. There is considerable variation in discharge to community rates within and across post-acute settings. Studies show geographic variation, variation across patient socioeconomic characteristics (for example, race and ethnicity), and variation by facility characteristics (for profit vs. nonprofit, freestanding vs. hospital-based, urban vs. rural). In the IRF setting, discharge to community rates vary across providers, ranging from about 60% to 75%. The 2015 MedPAC report shows that, in FY 2013, the facility-level, mean risk-adjusted discharge to community rate for IRFs within 100 days of admission was 75.8%, and the mean observed rate was 74.7%. Discharge to community rates also vary widely in the SNF setting, ranging from as low as 31% to as high as 65%. The 2015 MedPAC report shows a mean risk-adjusted discharge to community rate of 37.5% for SNFs within 100 days of admission, and mean observed rate of 40.1%. A multicenter study of 23 LTCHs reported that only 28.8% of 1,061 patients who were ventilator-dependent on admission were discharged to home or assisted living facility. A study of 66,510 Medicare beneficiaries during pre- and post-HH episodes, revealed that 64 percent of beneficiaries discharged from HH did not use any other Medicare-reimbursed acute or post-acute services in the 30 days following HH discharge. Significant numbers of patients were admitted to inpatient facilities (29 percent) and lesser numbers to skilled nursing facilities (7.6 percent), inpatient rehabilitation (1.5 percent) and home health (7.2 percent) or hospice (3.3 percent) within 30 days of HH discharge (Wolff et al., 2008).

    Measure Specifications




    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-1128)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medication review in post-acute care is generally considered to include medication reconciliation for all medications and medication review for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and medication review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    (New information provided by CMS on January 19, 2016) Medication review in post-acute care is generally considered to include medication reconciliation and drug regimen review for all medications and for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and drug regimen review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    Measure Specifications




    Medicare Spending per Beneficiary-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-287)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medicare payments to PAC have grown at a consistently higher rate than other major Medicare sectors. Between 2001 and 2013, Medicare PAC spending grew at an annual rate of 6.1 percent and doubled to $59.4 billion.

    Measure Specifications




    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-496)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The peer-reviewed literature specific to potentially preventable readmissions following IRF discharge is limited. However, MedPAC has estimated that 76 percent of 30-day readmissions for Medicare beneficiaries overall were due to five potentially preventable conditions (heart failure, electrolyte imbalance, respiratory infection, sepsis, and urinary tract infection (MedPAC 2007).

    Measure Specifications




    Potentially Preventable Within Stay Readmission Measure for Inpatient Rehabilitation Facilities (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-497)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The peer-reviewed literature specific to potentially preventable readmissions during an IRF stay is limited. However, MedPAC has estimated that 76 percent of 30-day readmissions for Medicare beneficiaries overall were due to five potentially preventable conditions (heart failure, electrolyte imbalance, respiratory infection, sepsis, and urinary tract infection (MedPAC 2007).

    Measure Specifications




    Compliance with Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar Trial (TCT) or Continuous Positive Airway Pressure (CPAP) Breathing Trial)) by Day 2 of the LTCH Stay (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-400)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Patients on invasive mechanical ventilation comprise a substantial proportion of LTCH patient admissions, and thus present a critical focus for assessment of high quality care. In Fiscal Year 2012, the LTCH MS-DRGs for “Respiratory system diagnosis with ventilator support 96+ hours” (MS-DRG-LTCH 207) and “Respiratory system diagnosis with ventilator support < 96 hours” (MS-DRG-LTCH 208) accounted for over 16,000 discharges, or greater than 13% of discharges. (MedPAC 2014). Mechanically ventilated patients are at higher risk of mortality, ventilator-associated pneumonia (Cook et al, 1998; Papazian et al., 1996; Vincent et al., 1995), delirium (Ely et al., 2001), ventilator associated lung injury (Meade et al., 1995 and 1997; Slutsky and Trembley, 1998), and other ventilator-associated events. The cost of invasive mechanical ventilation in LTCHs is considerable, estimated at $1.3 billion in 2006 (Kahn et al., 2010). Discontinuation of invasive mechanical ventilation is associated with improved patient outcomes, including lower post-discharge mortality (Aboussouan et al. 2008; Dermot Frengley et al. 2014; Hassenpflug, Steckart, and Nelson 2011). Citations: Aboussouan, L. S., Lattin, C. D., and Kline, J. L. (2008). 'Determinants of long-term mortality after prolonged mechanical ventilation'. Lung 186 (5):299-306, doi 10.1007/s00408-008-9110-x. Cook, D. J., Walter, S. D., Cook, R. J., Griffith, L. E., Guyatt, G. H., Leasa, D., Jaeschke, R. Z., and Brun-Buisson, C. (1998). 'Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients'. Ann Intern Med 129 (6):433-40. Dermot Frengley, J., Sansone, G. R., Shakya, K., and Kaner, R. J. (2014). 'Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival'. J Am Geriatr Soc 62 (1):1-9, doi 10.1111/jgs.12597. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001 Dec 5;286(21):2703-10. PMID: 11730446. Hassenpflug, M., Steckart, J., and Nelson, D. (2011). Post-ICU Mechanical Ventilation: Extended Care Facility Residents Transferred From Intensive Care To Long-Term Acute Care. In, American Thoracic Society 2011 International Conference. Denver, Colorado. Kahn, J. M., Benson, N. M., Appleby, D., Carson, S. S., and Iwashyna, T. J. (2010). 'Long-term acute care hospital utilization after critical illness'. JAMA 303 (22):2253-9, doi 10.1001/jama.2010.761. Meade, M. O., and Cook, D. J. (1995). 'The aetiology, consequences and prevention of barotrauma: a critical review of the literature'. Clin Intensive Care 6 (4):166-73. Meade, M. O., Cook, D. J., Kernerman, P., and Bernard, G. (1997). 'How to use articles about harm: the relationship between high tidal volumes, ventilating pressures, and ventilator-induced lung injury'. Crit Care Med 25 (11):1915-22. MedPAC. (2014). Chapter 11. Long-term Care Hospital Services. In: Report to the Congress: Medicare Payment Policy. In. Medicare Payment Advisory Commission, Washington, DC. Papazian, L., Bregeon, F., Thirion, X., Gregoire, R., Saux, P., Denis, J. P., Perin, G., Charrel, J., Dumon, J. F., Affray, J. P., and Gouin, F. (1996). 'Effect of ventilator-associated pneumonia on mortality and morbidity'. Am J Respir Crit Care Med 154 (1):91-7, doi 10.1164/ajrccm.154.1.8680705. Slutsky, A. S., and Tremblay, L. N. (1998). 'Multiple system organ failure. Is mechanical ventilation a contributing factor?'. Am J Respir Crit Care Med 157 (6 Pt 1):1721-5, doi 10.1164/ajrccm.157.6.9709092. Vincent, J. L., Bihari, D. J., Suter, P. M., Bruining, H. A., White, J., Nicolas-Chanoin, M. H., Wolff, M., Spencer, R. C., and Hemmer, M. (1995). 'The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee'. JAMA 274 (8):639-44.

    Measure Specifications




    Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-414)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The ultimate goals of post-acute care are avoiding institutionalization and returning patients to their previous level of independence and functioning, with discharge to community being the primary goal for the majority of post-acute patients. For many, home is a symbol of independence, privacy, and competence. Discharge to community is considered a valuable outcome to measure because it is a multifaceted measure that captures the patient’s functional status, cognitive capacity, physical ability, and availability of social support at home. There is considerable variation in discharge to community rates within and across post-acute settings. Studies show geographic variation, variation across patient socioeconomic characteristics (for example, race and ethnicity), and variation by facility characteristics (for profit vs. nonprofit, freestanding vs. hospital-based, urban vs. rural). In the IRF setting, discharge to community rates vary across providers, ranging from about 60% to 75%. The 2015 MedPAC report shows that, in FY 2013, the facility-level, mean risk-adjusted discharge to community rate for IRFs within 100 days of admission was 75.8%, and the mean observed rate was 74.7%. Discharge to community rates also vary widely in the SNF setting, ranging from as low as 31% to as high as 65%. The 2015 MedPAC report shows a mean risk-adjusted discharge to community rate of 37.5% for SNFs within 100 days of admission, and mean observed rate of 40.1%. A multicenter study of 23 LTCHs reported that only 28.8% of 1,061 patients who were ventilator-dependent on admission were discharged to home or assisted living facility. A study of 66,510 Medicare beneficiaries during pre- and post-HH episodes, revealed that 64 percent of beneficiaries discharged from HH did not use any other Medicare-reimbursed acute or post-acute services in the 30 days following HH discharge. Significant numbers of patients were admitted to inpatient facilities (29 percent) and lesser numbers to skilled nursing facilities (7.6 percent), inpatient rehabilitation (1.5 percent) and home health (7.2 percent) or hospice (3.3 percent) within 30 days of HH discharge (Wolff et al., 2008).

    Measure Specifications




    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-1129)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medication review in post-acute care is generally considered to include medication reconciliation for all medications and medication review for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and medication review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    (New information provided by CMS on January 19, 2016) Medication review in post-acute care is generally considered to include medication reconciliation and drug regimen review for all medications and for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and drug regimen review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    Measure Specifications




    Medicare Spending per Beneficiary-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-289)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medicare payments to PAC have grown at a consistently higher rate than other major Medicare sectors. Between 2001 and 2013, Medicare PAC spending grew at an annual rate of 6.1 percent and doubled to $59.4 billion.

    Measure Specifications




    Percent of Patients Who Received an Antipsychotic (AP) Medication (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-530)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Antipsychotic medication use is common among older adults in all post acute care settings. Antipsychotic medications can be potentially dangerous for the elderly, especially for those whom the medications are clinically indicated. Of particular concern is the off-label use of these drugs for older adults with dementia or dementia-related psychoses or agitation (Jeste et al., 2008). The FDA issued a black box warning against prescribing atypical antipsychotic medications for older adults with dementia in 2005 (Rosack, 2005). The evidence on which the warning is based on a meta-analysis of 17 randomized trials with a total of 5,106 patients that identified an “approximately 1.6- to 1.7-fold increase in mortality in the combined studies” (Rosack, 2005). Three years later, the FDA (June 2008) extended the warning to all categories of antipsychotic drugs (conventional & atypical). In addition to elevated mortality risk, elevated risk for serious adverse events such as falls, somnolence, and abnormal gait are results from clinical trials of atypical antipsychotic (AP) medications (Rosack, 2005; FDA, 2008; Ballard & Margallo-Lana, 2004; Martin et al., 2003; Neil, Curran, and Wattis, 2003; Doody et al., 2001; Jackson-Siegal, 2004). Also, there is evidence of increased risk for cerebrovascular adverse events associated with certain atypical antipsychotic medications (e.g., risperidone, olanzapine, and aripiprazole) (Jeste et al., 2008). Regardless of the warnings and potential adverse events, the administration of antipsychotic therapy is common and frequent among mechanically ventilated patients or among patients with delirium (Al-Qadheeb et al., 2013).

    Measure Specifications




    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-498)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The peer-reviewed literature specific to potentially preventable readmissions following LTCH discharge is limited. However, MedPAC has estimated that 76 percent of 30-day readmissions for Medicare beneficiaries overall were due to five potentially preventable conditions (heart failure, electrolyte imbalance, respiratory infection, sepsis, and urinary tract infection (MedPAC 2007).

    Measure Specifications




    Ventilator Weaning (Liberation) Rate (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-398)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Patients on invasive mechanical ventilation comprise a substantial proportion of LTCH patient admissions, and thus present a critical focus for assessment of high quality care. In Fiscal Year 2012, the LTCH MS-DRGs for “Respiratory system diagnosis with ventilator support 96+ hours” (MS-DRG-LTCH 207) and “Respiratory system diagnosis with ventilator support < 96 hours” (MS-DRG-LTCH 208) accounted for over 16,000 discharges, or greater than 13% of discharges. (MedPAC 2014). Mechanically ventilated patients are at higher risk of mortality, ventilator-associated pneumonia (Cook et al, 1998; Papazian et al., 1996; Vincent et al., 1995), delirium (Ely et al., 2001), ventilator associated lung injury (Meade et al., 1995 and 1997; Slutsky and Trembley, 1998), and other ventilator-associated events. The cost of invasive mechanical ventilation in LTCHs is considerable, estimated at $1.3 billion in 2006 (Kahn et al., 2010). Discontinuation of invasive mechanical ventilation is associated with improved patient outcomes, including lower post-discharge mortality (Aboussouan et al. 2008; Dermot Frengley et al. 2014; Hassenpflug, Steckart, and Nelson 2011). Citations: Aboussouan, L. S., Lattin, C. D., and Kline, J. L. (2008). 'Determinants of long-term mortality after prolonged mechanical ventilation'. Lung 186 (5):299-306, doi 10.1007/s00408-008-9110-x. Cook, D. J., Walter, S. D., Cook, R. J., Griffith, L. E., Guyatt, G. H., Leasa, D., Jaeschke, R. Z., and Brun-Buisson, C. (1998). 'Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients'. Ann Intern Med 129 (6):433-40. Dermot Frengley, J., Sansone, G. R., Shakya, K., and Kaner, R. J. (2014). 'Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival'. J Am Geriatr Soc 62 (1):1-9, doi 10.1111/jgs.12597. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001 Dec 5;286(21):2703-10. PMID: 11730446. Hassenpflug, M., Steckart, J., and Nelson, D. (2011). Post-ICU Mechanical Ventilation: Extended Care Facility Residents Transferred From Intensive Care To Long-Term Acute Care. In, American Thoracic Society 2011 International Conference. Denver, Colorado. Kahn, J. M., Benson, N. M., Appleby, D., Carson, S. S., and Iwashyna, T. J. (2010). 'Long-term acute care hospital utilization after critical illness'. JAMA 303 (22):2253-9, doi 10.1001/jama.2010.761. Meade, M. O., and Cook, D. J. (1995). 'The aetiology, consequences and prevention of barotrauma: a critical review of the literature'. Clin Intensive Care 6 (4):166-73. Meade, M. O., Cook, D. J., Kernerman, P., and Bernard, G. (1997). 'How to use articles about harm: the relationship between high tidal volumes, ventilating pressures, and ventilator-induced lung injury'. Crit Care Med 25 (11):1915-22. MedPAC. (2014). Chapter 11. Long-term Care Hospital Services. In: Report to the Congress: Medicare Payment Policy. In. Medicare Payment Advisory Commission, Washington, DC. Papazian, L., Bregeon, F., Thirion, X., Gregoire, R., Saux, P., Denis, J. P., Perin, G., Charrel, J., Dumon, J. F., Affray, J. P., and Gouin, F. (1996). 'Effect of ventilator-associated pneumonia on mortality and morbidity'. Am J Respir Crit Care Med 154 (1):91-7, doi 10.1164/ajrccm.154.1.8680705. Slutsky, A. S., and Tremblay, L. N. (1998). 'Multiple system organ failure. Is mechanical ventilation a contributing factor?'. Am J Respir Crit Care Med 157 (6 Pt 1):1721-5, doi 10.1164/ajrccm.157.6.9709092. Vincent, J. L., Bihari, D. J., Suter, P. M., Bruining, H. A., White, J., Nicolas-Chanoin, M. H., Wolff, M., Spencer, R. C., and Hemmer, M. (1995). 'The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee'. JAMA 274 (8):639-44.

    Measure Specifications




    30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-402)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    This measure complements the companion measure in symptomatic patients. The rationale for separating asymptomatic and symptomatic patients is that the recommended treatment criteria for each is different (stenosis grade) and a worse outcome score could be acceptable in symptomatic patients. This measure represents an unmet outcome measure for patients in multiple CMS programs.

    Measure Specifications




    Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-377)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Normalized lid position is the desired goal of surgery to improve clinical and functional outcomes for the patient

    Measure Specifications




    Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-396)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome

    Measure Specifications




    Acute Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-394)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life

    Measure Specifications




    Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-412)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The Villalta score is a well-recognized composite score that integrates patient reported symptoms with signs of the severity of post-thrombotic syndrome in patients with ilio-femoral venous disease (hence represents both PRO and an intermediate outcome measures). It is simple to administer clinically and is a reliable measure to ascertain both the clinical severity as well as morbidity associated with post-thrombotic syndrome. There is a measure gap in the area of venous disease and this measure will help to address this. The Villalta score can be integrated into structured reporting that is being piloted by the SIR, potentially enabling QCDR level reporting of the measure. An advantage over surveys is that this scoring system can be use uniformly by many sites. A disadvantage over surveys is that patients must be seen to have the follow-up score documented.

    Measure Specifications




    Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-399)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome

    Measure Specifications




    Chronic Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-397)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life

    Measure Specifications




    Common femoral arterial access site complication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-424)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Arterial access is a critical step for any arterial vascular intervention and is performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Arterial access site complications are a significant contributor to patient discomfort and morbidity in the perioperative period, and are a fortunately rare cause for mortality. Common femoral arterial access is by far the most common site of access for a variety of endovascular procedures. The size of the arterial access and the presence of underlying vascular disease are predisposing factors to arterial access site complications. This measure is intended to focus on access site complications using 8Fr or small sheath sizes, and can be reported in any center performing arterial procedures as a measure of quality patient care. The rationale to limit the upper size of the access to 8Fr is to limit the measure to procedures with exclusively percutaneous access. Physicians using this measure are free to utilize Ultrasound for arterial access and can report the measure regardless if they use closure devices or rely on manual pressure as a strategy for achieving hemostasis. There is significant morbidity that may result from procedures performed downstream on patients with access site complications, including open repair of the injured artery site. The SIR Clinical Practice Guidelines (JVIR 2003, Vol 14, Issue 9, Part 2, S283-288) have noted that modest hematomas from femoral arterial access occur in up to 10% of patients, whereas major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable. As proposed this measure compliments a measure being considered for the 2016 PQRS program entitled ""Rate of surgical conversion from lower extremity endovascular revascularization procedure"" by detailing access site complications specifically. Access site complications are a modifiable risk factor for surgical conversion in lower extremity arterial procedures specifically."

    Measure Specifications




    Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-461)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The primary treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis +/-para-aortic region with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased pelvic failure rates and decreased cancer specific and overall survival. Pelvic failure rates were reported at 26% for women who required greater than 56 days compared to 9% (hazard ratio 3.8; p=0.02). In an ancillary analysis of a Gynecologic Oncology Group study (protocol 165), women who had prolongation of radiation for any cause had a poorer progression free survival (HR 1.98; CI 1.16-3.38) and overall survival (HR 1.88; CI 1.08-3.26) compared to those who completed therapy within 8 weeks. Further studies have shown that prolongation of radiation is associated with a decreased survival of 0.6% and pelvic control rates of 0.7% for each additional day beyond 55 days for all stages of disease. More recent studies have shown that this effect remains even in the setting of chemoradiation. References: 1. Song S, Rudra S, Hasselle MD, et al. The effect of treatment time in locally advanced cervical cancer in the era of concurrent chemoradiotherapy. Cancer 2013;119(2):325-331. 2. Fyles A, Keane TJ, Barton M, Simm J. The effect of treatment duration in the local control of cervix cancer. Radiother Oncol 1992;25(4): 273-9. 3. Nugent EK, Case AS, Hoff JT, et al. Chemoradiation in locally advanced cervical carcinoma: an analysis of cisplatin dosing and other clinical prognostic factors. Gynecol Oncol 2010;116(3):438-41. 4. Monk BJ, Tian C, Rose PG, Lanciano R. Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials. Gynecol Oncol 2007;427-433. 5. Petereit DG, Sarkaria JN, Chappell R, Fowler JF, Harmann TJ, Kinsella TJ et al . The adverse effect of treatment prolongation in cervical carcinoma. Int J Radiation Oncology Biol Phys 1995;32(5):1301-1307. 6. Perez CA, Grigsby PW, Castro-Vita H, Lockett MA. Carcinoma of the uterine cervix. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Int J Radiation Oncology Biol Phys 1995;32(5): 1275-1288.

    Measure Specifications




    Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-370)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Improved visual acuity is a desired surgical goal to improve patient's daily activities of daily living and quality of life

    Measure Specifications




    Diabetic Macular Edema: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-393)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life

    Measure Specifications




    Documentation of offering a trial of conservative management prior to fecal incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-440)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    This measure is intended to ensure that patients are offered the opportunity to pursue conservative management prior to surgery. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback is associated with satisfaction rates of up to 76%, and continence in 55%. Patient education on all the treatment options can help with patient satisfaction and better outcomes as they still can be used as adjunct therapies to surgery. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Whitehead WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):138-46; quiz 147. doi: 10.1038/ajg.2014.303. Epub 2014 Oct 21. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):127-36. doi: 10.1038/ajg.2014.396. Epub 2014 Dec 23.

    Measure Specifications




    Documentation of offering a trial of conservative management prior to urgency incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-441)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Urge urinary incontinence negatively impacts patients' quality of life, as patients may limit activities outside the home, socializing, and sexual activity due to the fear of leaking. Current guidelines issued by the American Urologic Association state that behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) should be first line therapy. Clinicians should offer oral anti-muscarinics or oral beta 3-adrenoceptor agonists as second-line therapy. Third line therapies include intradetrusor Botox injections, peripheral tibial nerve stimulation, or sacral neuromodulation. Website reference: https://www.auanet.org/education/guidelines/overactive-bladder.cfm

    Measure Specifications




    Efficacy of uterine artery embolization for symptomatic uterine fibroids (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-423)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Uterine artery embolization is a well-established procedure for the treatment of symptomatic uterine fibroids, with reported success rates of 85% in patients with isolated uterine fibroids as the etiology of their symptoms. Although there are a variety of techniques that are used clinically, such variance has little impact on the overall patient outcome. The development of uterine fibroid disease specific surveys, such as the Uterine Fibroid Symptom Health-related Quality of Life Questionnaire (UFS-QOL) has enabled robust reporting of patient-reported outcomes for this disease (http://www.sirfoundation.org/registries/). Importantly, this survey enables assessment both of the patient's subjective symptoms as well as their experience. The routine use of this survey instrument would objectively assess the procedural efficacy at the patient level.

    Measure Specifications




    Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-379)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life

    Measure Specifications




    Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-372)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome

    Measure Specifications




    Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-374)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome

    Measure Specifications




    Hepatitis A vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-210)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)

    Measure Specifications




    Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-220)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes

    Measure Specifications




    Hepatitis B vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-211)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)

    Measure Specifications




    Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-229)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Achieving SVR is the first step toward reducing future HCV morbidity and mortality. Once achieved, an SVR is associated with long-term clearance of HCV infection, which is regarded as a virologic ‘‘cure,’’ as well as with improved morbidity and mortality. Patients who achieve an SVR usually have improvement in liver histology and clinical outcomes. Nineteen cohort studies (n=105 to 16,864) evaluated the association between SVR after antiviral therapy and mortality or complications of chronic HCV infection. Duration of follow-up ranged from 3 to 9 years. Ten studies were conducted in Asia (60, 67-72, 75, 77, 78). Eight (64-66, 72, 75-78) were rated as poor-quality and the remainder as fair quality. Although all studies reported adjusted risk estimates, only 8 (60, 61, 63, 67-70, 73) evaluated 5 key confounders (age, sex, genotype, viral load, and fibrosis stage). No study clearly described assessment of outcomes blinded to SVR status. The largest study (n=16,864) had the fewest methodological shortcomings (61). It adjusted for multiple potential confounders, including age, sex viral load, presence of cirrhosis, multiple comorbid conditions, aminotransferase levels, and others. It also stratified results by genotype. In a predominantly male, Veterans Affairs population, SVR after antiviral therapy was associated with lower risk for all-cause mortality than was SVR , after median of 3.8 years (adjusted hazard ration, 0.71 [CI, 0.60 to 0.861], 0.62[CI, 0.44 to 0.87], and 0.51 [CI, 0.35 to 0.75] for genotypes 1, 2, and 3 respectively). Mortality curves began to separate as soon as 3 to 6 months after SVR assessment. Eighteen other cohort studies also found SVR to be associated with decreased risk for all-cause mortality (adjusted hazard rations, 0.07 to 0.39)(60, 69, 72, 73, 75-78), liver-related mortality (adjusted hazard rations, 0.12 to 0.46)(60, 62, 63, 67, 68, 71, 73-76, 78), and other complications of end-stage liver disease versus no SVR, with effects larger than in the Veterans Affairs study. The subgroup of studies that focused on patients with advanced fibrosis or cirrhosis at baseline (60, 67-72, 75, 77, 78) reported similar risk estimates. (Chou et. al., 2015) Chou R, Hartung D, Rahman B, Wasson N, Cottrell EB, Fu R. Comparative effectiveness of antiviral treatment for hepatitis C virus infection in adults: a systematic review. Ann Intern Med. 2013 Jan 15;158(2):114-23. Review. PubMed PMID: 23437439

    Measure Specifications




    HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-230)

    Summary of Workgroup Deliberations

    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 U.S. Preventive Services Task Force (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 underlying the USPSTF recommendation 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) Notably, the current USPSTF 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. CDC's newly published 2015 STD Treatment Guidelines also underscore the need for HIV testing in the context of certain STD diagnoses, noting that: “Persons at high risk for HIV infection with early syphilis, gonorrhea, or chlamydia should be screened at the time of the STD diagnosis, even if an HIV test was recently performed. Some STDs, especially rectal gonorrhea and syphilis, are a risk marker for HIV acquisition." Relevant references supporting the 2015 STD Treatment Guidelines include: • Zetola NM, Bernstein KT, Wong E, et al. Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs. J Acquir Immune Defic Syndr 2009;50:546–51. • Pathela P, Braunstein SL, Blank S, et al. HIV incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV case registry. Clin Infect Dis 2013;57:1203–9. • Peterman TA, Newman DR, Maddox L, Schmitt K, Shiver S. Risk for HIV following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida, 2000-2011. Int J STD AIDS. 2015 Feb;26(2):113-9. doi: 10.1177/0956462414531243. Epub 2014 Apr 8. • Taylor MM, Newman DR, Gonzalez J, Skinner J, Khurana R, Mickey T. HIV status and viral loads among men testing positive for rectal gonorrhoea and chlamydia, Maricopa County, Arizona, USA, 2011-2013. HIV Med. 2015 Apr;16(4):249-54. doi: 10.1111/hiv.12192. Epub 2014 Sep 17

    Measure Specifications




    Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-413)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The venous clinical severity score replace the older CEAP (clinical grade, etiology, anatomy, pathophysiology) grading system to assess the severity of chronic venous disease. Unlike the CEAP system, the venous clinical severity score is more useful in the assessment of changes in venous disease and thus is most appropriate to apply to patients undergoing treatment to assess outcomes from therapy, such as ilio-femoral venous stenting. This measure addresses a measurement gap across multiple programs. By encouraging the routine use of the venous clinical severity score centers will be able to objectively assess the intermediate outcome of venous stenting on the symptoms and signs of chronic venous disease. This score focuses more on the clinical signs, rather than patient symptoms, which was demonstrated to be a more useful marker for subtle changes in the severity of venous disease.

    Measure Specifications




    Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-450)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). IP chemotherapy provides a superior OS in patients after optimal cytoreductive surgery (Walker JL, Armstrong DK, Huang HQ, Fowler J, Webster K, Burger RA, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study. Gynecologic oncology. 2006;100:27-32. PMID=16368440)

    Measure Specifications




    Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-275)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. References: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 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- http://circ.ahajournals.org/search?tocsectionid=ACC/AHA+Prevention+Guideline&sortspec=date&submit=Submit AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update http://content.onlinejacc.org/article.aspx?articleid=1127560 The All or None (Composite) method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in one score patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.

    Measure Specifications




    Minimally invasive surgery performed for patients with endometrial cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-452)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    A total of 8 randomized clinical trials investigating minimally invasive surgery compared to laparotomy in over 3500 patients showed no difference in overall or disease free survival (Cochrane Database Syst Rev. 2012 Sep 12;9; J Clin Oncol. 2012 Mar 1;30(7):695-700; J Clin Oncol. 2009 Nov 10;27(32):5331-6). However, patients undergoing minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks (Lancet Oncol. 2010 Aug;11(8):772-80.; J Clin Oncol. 2009 Nov 10;27(32):5337-42). Furthermore, the rate of severe postoperative adverse events was lower in patients undergoing minimally invasive surgery (Cochrane Database Syst Rev. 2012 Sep 12;9). Despite these known benefits, utilization rates of minimally invasive surgery vary from 50-90% between surgeons and institutions (unpublished data from Nationwide inpatient sample - delete this sentence if reference required). References: 1: Galaal K, Bryant A, Fisher AD, Al-Khaduri M, Kew F, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2012 Sep 12;9:CD006655. doi: 10.1002/14651858.CD006655.pub2. Review. PubMed PMID: 22972096. 2: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Barakat R, Pearl ML, Sharma SK. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012 Mar 1;30(7):695-700. doi: 10.1200/JCO.2011.38.8645. Epub 2012 Jan 30. Erratum in: J Clin Oncol. 2012 May 1;30(13):1570. PubMed PMID: 22291074; PubMed Central PMCID: PMC3295548. 3: Janda M, Gebski V, Brand A, Hogg R, Jobling TW, Land R, Manolitsas T, McCartney A, Nascimento M, Neesham D, Nicklin JL, Oehler MK, Otton G, Perrin L, Salfinger S, Hammond I, Leung Y, Walsh T, Sykes P, Ngan H, Garrett A, Laney M, Ng TY, Tam K, Chan K, Wrede CD, Pather S, Simcock B, Farrell R, Obermair A. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncol. 2010 Aug;11(8):772-80. doi: 10.1016/S1470-2045(10)70145-5. Epub 2010 Jul 16. PubMed PMID: 20638899. 4: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Spiegel G, Barakat R, Pearl ML, Sharma SK. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009 Nov 10;27(32):5331-6. doi: 10.1200/JCO.2009.22.3248. Epub 2009 Oct 5. PubMed PMID: 19805679; PubMed Central PMCID: PMC2773219. 5: Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009 Nov 10;27(32):5337-42. doi: 10.1200/JCO.2009.22.3529. Epub 2009 Oct 5. Erratum in: J Clin Oncol. 2010 Jun 1;28(16):2805. PubMed PMID: 19805678; PubMed Central PMCID: PMC2773220.

    Measure Specifications




    New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-296)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Corneal abrasion/injury is the most common ophthalmologic complication that occurs during general anesthesia for non-ocular surgery. These injuries are painful for the patient, and can lead to significant microbial keratitis with possibility of permanent scarring. There is no standardized method for protecting the eyes during an anesthetic for non-ocular surgery. Adhesive tape, individual single, sterile packaged eye covers, small bio-occlusive dressings, used with or without eye ointment are some of the options used. Some practitioners may simply observe closed, non-taped eyes. The specific type of eye ointment also varies significantly. Some ointment is made with petrolatum, some is water soluble, with or without preservatives. If ointment is used, preservative-free eye ointment is preferred, because preservative can cause corneal epithelial sloughing and conjunctiva hyperemia. None of the methods described in the literature are entirely effective at preventing corneal injury and some are associated with unwanted side effects. It is important to know that petrolatum is flammable and should be avoided when cautery will be used near the face. Several large studies have demonstrated that applying these techniques while measuring performance can lead to significant improvements in patient care. Measuring the incidence of corneal injury will give practices the data they need to assess performance, compare to national benchmarks, and if gaps are identified, undertake measures to improve eye protection for patients. The net result will be reduced corneal injuries and patient discomfort. All eye trauma cases and all eye surgery cases will be excluded from the measure. Reporting separately those procedures done on the face, including the ear, nose, and mandible, will serve as stratification allowing comparison of procedures which most anesthesiologists believe have a higher risk of corneal injury and which also remove the eyes from the direct control of the anesthesiologist.

    Measure Specifications




    NMSC: Biopsy Reporting Time - Pathologist (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-216)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The communication between pathologists and physicians about patient outcomes is fragmented. Effective and timely communication through the biopsy report between the two practitioners is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can increase the cost of medical care and error. This measure seeks to standardize the amount of time it takes for the pathologist to send the final biopsy report to the biopsying physician to ensure timely communication and effective treatment for the patient.

    Measure Specifications




    Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-392)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life

    Measure Specifications




    Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-215)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Effective and timely communication between the physician and patient about biopsy results is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can negatively affect patient experience and satisfaction by increasing the anxiety the patient experiences while waiting for results. This measure seeks to standardize the amount of time it takes for the clinician to notify patients of the final biopsy results, to ensure timely communication and effective treatment for the patient.

    Measure Specifications




    Non-Recommended PSA-Based Screening (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1019)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation). This recommendation applies to men in the general U.S. population, regardless of age.” The Agency for Healthcare Research and Quality (AHRQ) looked at five randomized controlled trials (RCTs) and two meta-analyses and found inconsistency regarding the efficacy of PSA-based screening, although the high-quality surveyed studies are limited to interim results and do not consider potential psychological harms.

    Measure Specifications




    Non-selective beta blocker use in patients with esophageal varices (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-209)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Use on non-selective beta blockers in the setting of esophageal varices can reduce portal pressure and improve long term clinical outcomes. American Association for the Study of Liver Diseases Guidelines 2009

    Measure Specifications




    Over-utilization of mesh in the posterior compartment (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-436)

    Summary of Workgroup Deliberations

    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), with the lifetime risk for undergoing surgery for pelvic organ prolapse recently estimated to have doubled to 20% (Obstet and Gynecol 2014;123:1201-6). Repairs of the posterior compartment can include a midline fascial plication, site-specific repair, or a graft-augmented repair. Studies have failed to demonstrate any significant benefit to the utilization of synthetic mesh augments in the posterior compartment (Am J Obstet Gynecol 2006;195:1762-71) and recent concerns have come to light regarding the use of synthetic mesh augments (FDA Urogynecologic Surgical Mesh : Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse; July 2011). Implementation of this measure will determine if best care practices are being followed when treating women with disorder.

    Measure Specifications




    Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-928)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Depression is a common and treatable mental disorder. The Centers for Disease Control and Prevention states that an estimated 6.6% of the U.S. adult population (14.8 million people) experiences a major depressive disorder during any given 12-month period. Additionally, dysthymia accounts for an additional 3.3 million Americans. In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression.[1] 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.[2] Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more likely to take their own lives than people who are not depressed and five times more likely to abuse drugs.[3] Depression is the leading cause of medical disability for people aged 14 – 44.[4] Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability. People who suffer from depression have lower incomes, lower educational attainment and fewer days working days each year, leading to seven fewer weeks of work per year, a loss of 20% in potential income and a lifetime loss for each family who has a depressed family member of $300,000.[5] The cost of depression (lost productivity and increased medical expense) in the United States is $83 billion each year.[6] 1. CDC. Current Depression Among Adults --- United States, 2006 and 2008. MMWR 2010;59(38);1229-1235. 2. Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv 2008;59:1383--90. 3. Joiner, Thomas Myths about suicide. Cambridge, MA, US: Harvard University Press. (2010). 288 pp. 4. Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. Journal of the American Medical Association, 289, 3135-3144. 5. Smith, J. P., & Smith, G. C. (2010). Long-term economic costs of psychological problems during childhood. Social Science & Medicine, 71, 110-115. 6. Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leong, S. A., Lowe, S. W., Berglund, P. A., et al. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64, 1465-1475. More detailed information about the rationale and history of this measure and its components are available in the MNCM measure submission forms for the most recent NQF Behavioral Health measure endorsement project. Links are in the final committee report available here: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx.

    Measure Specifications




    Patient reported outcomes following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-411)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Ilio-venous stenting is a commonly performed procedure in patients with deep venous disease including acute, acute-on-chronic, and chronic venous thrombosis. Such interventions are also performed in patients with venous stenosis, such as patient with May-Turner syndrome. The procedural outcome of such procedures does not necessarily reflect resolution of patient symptoms, however. Standardizing the use of disease-specific surveys in this patient population is necessary to objectively assess the success of ilio-femoral venous stenting. Each survey is different; an objective outcome of any improvement would be the most appropriate assessment to encourage use of this measure by a wide variety of providers. This measure compliments a measure being considered for the 2016 PQRS program, focused on the PRO in patients undergoing saphenous vein ablation.

    Measure Specifications




    Patient-Reported Functional Communication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-313)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Patient engagement and their perceptions of their hearing abilities is necessary to determine patient-centered goals and treatment. There are several standardized, validated patient questionnaires available to capture the patient's perception of their communication abilities in their activities of daily living that can be used with objective measures of communication and hearing to offer a complete picture of the patient's functional ability. Using these tools assists the audiologist with rehabilitation goals and care planning, and engages the patient in the development of their own functional goals. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care and actively engage patients in the diagnosis and treatment of their hearing loss.

    Measure Specifications




    Performance of objective measure of functional hearing status (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-307)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Functional hearing measurements are necessary to supplement the findings of the hearing thresholds and capture the patient's ability to communicate, and should be incorporated into the diagnosis and treatment of bilateral, permanent hearing loss. The data captured in objective measurement of open-set speech recognition, introduced with the presence of noise, can help audiologists objectively measure improvement and outcomes with amplification and rehabilitation and be used as a tool to educate patients on their hearing perception abilities. Additionally, functional hearing is a necessary measurement to determine cochlear implant candidacy. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care.

    Measure Specifications




    Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-465)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The primary treatment of stage IB1-IIA is radical hysterectomy. Unlike simple hysterectomy, radical hysterectomy includes removal of the paracervical tissue including the parametrium, uterosacral ligament, and uper vagina. Radical hysterectomy has long been considered the most appropriate type of hysterectomy for invasive cervical cancer. The procedure requires expertise and technical skill to perform. Radical hysterectomy can be performed via laparotomy, through minimally invasive technology (robotic or laparoscopic) or vaginally.

    Measure Specifications




    Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-454)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a suboptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686).

    Measure Specifications




    Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-466)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    There have been multiple prospective randomized trials demonstrating the disease free and overall survival for cervical cancer patients with post-operative involvement of surgical margins, and/or regional lymph nodes. These collective studies have resulted in the recommendation by the National Cancer Institute that platinum containing chemotherapy be added to post-operative radiation therapy for patients with positive surgical margins including the parametrium and vagina, as well as positive lymph nodes. The following articles are referenced in the NCI alert: Morris et al NEJM 1999;340:1137-1143, Peters et al JCO 2000;18:1606-1613, Rose, P. et al NEJM 1999;340:1144-1153

    Measure Specifications




    Potential Opioid Overuse (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1169)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Considerable evidence indicates that opioid overuse is an important issue. The 2014 U.S. Department of Health and Human Services (HHS) National Action Plan for Adverse Drug Event Prevention highlighted the need for safer prescribing and monitoring of opioids. Patients prescribed high-dose opioids have an approximately 10-fold increase in risk of overdose compared with those prescribed low-dose opioids (Edlund et al. 2014). Patients on high-dose opioids are less likely to receive care consistent with guidelines and appropriate monitoring (Morasco et al. 2010). High daily dose is the most common indicator of potential opioid misuse or inappropriate prescribing practices for opioids (Liu et al. 2013). The Secretary’s Opioid Initiative (2015) includes improved prescribing practices as one of the Departments top three priorities on opioids: http://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths .

    Measure Specifications




    PQI 91 Prevention Quality Acute Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-577)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. The PQIs are population based.

    Measure Specifications




    Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-576)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    2 component measures already in the program.

    Measure Specifications




    Proportion admitted to hospice for less than 3 days (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-415)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Earlier referral and admission to hospice allows patients to derive the maximal benefit from it

    Measure Specifications

    Summary of NQF Endorsement Review




    Rate of adequate percutaneous image-guided biopsy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-420)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The success rate of percutaneous biopsy is determined by the suitability of the sample for pathological analysis. Patients in whom a biopsy procedure yields inadequate specimens for analysis may be referred for repeat percutaneous biopsy, open biopsy, or undergo imaging to assess for alternative sites for biopsy increasing costs to the system, necessitating a second procedure or imaging test, and resulting in a delay in diagnosis. This measure provides an overall assessment of effective biopsy sampling, which directly influences the patient experience and is an important component of efficient patient care. Evidence to support this measure comes from several published studies which were reviewed in a SIR Standards of Practice Document published in 2010 (Gupta S, Wallace MJ, Cardella JF et al. Quality Improvement Guidelines for Percutaneous Needle Biopsy. JVIR 2010; 21:969=975). The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. The consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes. It is important to note that when a biopsy sample is considered inadequate for analysis, the patient will likely require a second biopsy procedure, either by the same operator or via a second approach with a different operator increasing costs to payers. The proposed metric is intended not to penalize operators for attempting difficult percutaneous biopsies, but rather to place a priority on working with pathology to ensure adequacy of sampling in a single procedure. This measure is a modified measure as submitted for consideration last year, focusing on a different strategy for data capture.

    Measure Specifications




    Route of hysterectomy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-437)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The purpose of this measure is to ensure that vaginal hysterectomy, the safest mode of hysterectomy, is optimized as a treatment option for patients requiring hysterectomy for benign indications. A Cochrane review evaluating route of hysterectomy asserts that vaginal hysterectomy is the safest mode of hysterectomy and is associated with fewer complications and better outcomes (Cochrane Database of Systematic Reviews 2009, Issue 3), and the American College of Obstetrics and Gynecology Committee Opinion (Number 444 Nov 2009) asserts that vaginal hysterectomy is the approach of choice whenever feasible.

    Measure Specifications




    Screening endoscopy for varices in patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-251)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Early detection of varices in cirrhotic patients can improve long term survival

    Measure Specifications




    Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-217)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Early detection of hepatomas in patients with Chronic Hepatitis B can improve long term survival.

    Measure Specifications




    Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-375)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes

    Measure Specifications




    Surgical staging with lymph node removal for any grade 3 and/or myometrial invasion >50% with endometrial cancer (Measure removed from consideration by CMS on 12/1/2015) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-459)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Grade 3 tumors with greater than 50% myometrial invasion are at a higher risk of distant/metastatic spread. The decision to recommend adjuvant chemotherapy and/or radiation has advantages to patient outcomes in advanced stage diseases and if a lymph node dissection is not performed, patient stage status is known and women maybe undertreated or overtreated. The absence of an appropriate measure of this nature has the risk of women having surgery performed by General Gynecologists without the surgical expertise to perform a lymph node dissection. (1)National Cancer Center Network Clinical Practice Guidelines in Oncology. Uterine Neoplasms. 2014

    Measure Specifications




    Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-212)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Early detection of dysplasia or cancer in colonic Crohn’s Disease patients can improve long term survival. All patients with diagnosis colonic Crohn’s Disease for > 10 years should have a surveillance colonoscopy every 1-2 years (American Society of Gastrointestinal Endoscopy Guidelines 2006)

    Measure Specifications




    Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-221)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Early detection of dysplasia or cancer in ulcerative colitis patients can improve long term survival ACG guideline 2010

    Measure Specifications




    Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-208)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's Esophagus. Patients with esophageal dyslasia and esophageal cancer are often asymptomatic until later stages. Earlier detection can improve outcomes. American College of Gastroenterology Guidelines 2008

    Measure Specifications




    Testing for uterine disease prior to obliterative procedures (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-439)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to colpocleisis. Thus avoiding the lack of access to the uterus for proper work up and allowing proper referral 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%). 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




    Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-460)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Women with early stage cervical cancer who are not operative candidates and those with stage 1B2 or higher stage cancers are typically recommended to undergo radiation therapy with external beam radiation and brachytherapy. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. Four year causes specific survival improved with the use of brachytherapy (64.3% with brachytherapy v. 51.1% without) as did overall survival (58.2% with brachytherapy v. 46.2% without) based on SEER data (Han K et al. Int J Rad Onc, Biol, Phys. 2013;87:111-119). Similar results were seen in a recent study from the National Cancer Database with a median overall survival of 63.3 months in patients who did receive brachytherapy and 27.2 months among patients who did not (Lin JF et al. Gynecol Oncol. 2014;132:416-422). These studies also showed that only 47.5-58% of women are treated with brachytherapy in addition to their external beam therapy and that rates of use of brachytherapy have declined over time. The declination in use is attributed to inadequate training and unavailability of appropriate technology in small hospitals.

    Measure Specifications




    Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-463)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The addition of platinum-based chemotherapy to primary radiation therapy in the treatment of patients with stage IIB-IV cervical cancer is associated with a significant progression-free and overall survival benefit. This finding was demonstrated in five landmark randomized clinical trials, which led to the National Cancer Institute (NCI) clinical alert in 1999 that established the addition of chemotherapy to radiation therapy as standard of care for cervical cancer patients. Subsequently, the Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration published a Cochrane Database systemic review and meta-analysis, confirming the findings of the initial trials. The review and meta-analysis demonstrated that the addition of platinum-based chemotherapy was associated with a 17% improvement in overall survival (HR = 0.83, 95% CI 0.71- 0.97, P = 0.017). The addition of chemotherapy to radiation therapy also improved disease-free survival by 22% (HR 0.78, 95% CI 0.70 - 0.87, P < 0.001). The benefit of platinum-based chemotherapy to primary radiation therapy in the treatment of stage IIB-IV cervical cancer patients has been clearly demonstrated. However, there is a paucity of data on how often healthcare providers and institutions are meeting this standard of care. REFERENCES Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD008285. doi: 10.1002/14651858.CD008285.

    Measure Specifications




    Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-179)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of truncal squamous cell carcinoma in situ (SCCis) and keratoacanthoma type squamous cell carcinoma (SCC-KA) that are 1 cm or smaller in immunocompetent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.

    Measure Specifications




    Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-178)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of superficial basal cell carcinoma (BCC) on the trunk in immune-competent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.

    Measure Specifications




    Use Of Preventive Screening Protocol For Transplant Patients (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-177)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    It is well-established in the literature that organ transplant recipients (OTRs) have increased incidences of NMSC overtime. It is essential to provide a protocol to ensure that OTRs receive appropriate levels of health promotion from their provider. This measure seeks to ensure health promotion using three tiers to increase knowledge, screenings, and protective methods to limit the morbidity and mortality that can result from non-melanoma skin cancer (NMSC).

    Measure Specifications




    Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-434)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Given the increasing number of women undergoing ambulatory surgical procedures for UI from 34,968 in 1996 to 105,656 in 2006, the need and demand for treatment of UI will rise significantly due to current changes in demographics (Erekson EA, 2010, Ambulatory procedures for female pelvic disorders in the United States). The procedures include the slings if the urethra hypermobile or bulking agents for fixed (ISD) urethra. The effectiveness of a sling decreases from 90% to 50% in someone with ISD. ISD criteria usually: not mobile urethra, VLPP less than 60mm H2O or MUCP less than 20mm H2O. Patients with ISD. Bulking agents are effective 70-80% in patients with ISD. Use of bulking agents should be utilized in appropriate patients with ISD.

    Measure Specifications




    Advance Care Plan (Program: Medicare Shared Savings Program; MUC ID: MUC15-578)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Addresses a gap in patient and family centered care, aligns with PQRS, and aligns with recent CMS payment policy supporting advance care planning between providers and patients/caregivers.

    Measure Specifications

    Summary of NQF Endorsement Review




    Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (Program: Medicare Shared Savings Program; MUC ID: MUC15-579)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Complications associated with falls affect many patients.

    Measure Specifications

    Summary of NQF Endorsement Review




    Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Medicare Shared Savings Program; MUC ID: MUC15-275)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. References: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 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- http://circ.ahajournals.org/search?tocsectionid=ACC/AHA+Prevention+Guideline&sortspec=date&submit=Submit AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update http://content.onlinejacc.org/article.aspx?articleid=1127560 The All or None (Composite) method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in one score patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.

    Measure Specifications




    PQI 91 Prevention Quality Acute Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-577)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. The PQIs are population based.

    Measure Specifications




    Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-576)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    2 component measures already in the program.

    Measure Specifications




    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-951)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Cancer patients receiving chemotherapy have much higher rates of admissions and ED use than other patients. A study of 2007 commercial claims data for more than 14 million patients found that cancer patients average one admission per year; 40 percent of those admissions were chemotherapy related (Kolodziej et al. 2011). The authors also found that cancer patients average approximately two ED visits per year, about half of which were chemotherapy related. Common complications of chemotherapy treatment include nausea, emesis, anemia, neutropenic fever, diarrhea, dehydration, and pain (Burton et al. 2007; Crawford et al. 2004; Groopman and Itri 2000; Osoba et al. 1997; Richardson and Dobish 2007; Stein et al. 2010). Chemotherapy-related admissions and ED visits may be due to outpatient chemotherapy patients having unmet needs and gaps in care, which, if addressed, could reduce admissions and ED visits and increase patients’ quality of life (Hassett et al. 2006; Mayer et al. 2011; McKenzie et al. 2011). Although it is extremely unlikely that all admissions and ED visits related to chemotherapy can be avoided by prevention and treatment of side effects and complications, there is evidence and consensus among providers on ways to prevent and treat each of the symptoms included in the numerator of this measure. Measurement of admissions and ED visits for patients receiving outpatient chemotherapy should encourage reporting facilities to take steps to prevent and improve management of side effects and complications from treatment. Poor performance on the measure would reflect high resource use and significant consequences for patient/society due to poor quality; admissions and ED visits are costly to payers and reduce quality of life for patients. Burton, A.W., G.J. Fanciullo, R.D. Beasley, and M.J. Fisch. “Chronic Pain in the Cancer Survivor: A New Frontier”. Pain Medicine, vol. 8, 2007, pp. 189–198. Crawford, J.C., D.C. Dale, and G.H. Lyman. “Chemotherapy-Induced Neutropenia.” Cancer, vol. 15, 2004, pp. 228–237. Groopman, J.E., and L.M. Itri. “Chemotherapy-Induced Anemia in Adults: Incidence and Treatment.” Journal of the National Cancer Institute, vol. 91, 2000, pp. 1616–1634. Hassett, M.J., J. O’Malley, J.R. Pakes, J.P. Newhouse, and C.C. Earle. “Frequency and Cost of Chemotherapy-Related Serious Adverse Effects in a Population Sample of Women with Breast Cancer.” Journal of the National Cancer Institute, vol. 98, no. 16, 2006, pp. 1108–1117. Kolodziej, M., J.R. Hoverman, J.S. Garey, J. Espirito, S. Sheth, A. Ginsburg, M.A. Neubauer, D. Patt, B. Brooks, C. White, M. Sitarik, R. Anderson, and R. Beveridge. “Benchmarks for Value in Cancer Care: An Analysis of a Large Commercial Population.” Journal of Oncology Practice, vol. 7, 2011, pp. 301–306. Mayer, D.K., D. Travers, A. Wyss, A. Leak, A. Waller. “Why Do Patients with Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina.” Journal of Clinical Oncology, vol. 26, no. 19, 2011, pp. 2683–2688. McKenzie, H., L. Hayes, K. White, K. Cox, J. Fethney, M. Boughton, and J. Dunn. “Chemotherapy Outpatients’ Unplanned Presentations to Hospital: A Retrospective Study.” Support Care Cancer, vol. 19, 2011, pp. 963–969. Osoba, D., B. Zee, D. Warr, J. Latreilee, L. Kaizer, and J. Pater. “Effect of Postchemotherapy Nausea and Vomiting on Health-Related Quality of Life.” Support Care Cancer, vol. 5, 1997, pp. 307–313. Richardson, G., and R. Dobish. “Chemotherapy Induced Diarrhea.” Journal of Oncology Pharmacy Practice, vol. 13, no.4, 2007, pp. 181–98. Stein, A., W. Voigt, and K. Jordan. “Chemotherapy-Induced Diarrhea: Pathophysiology, Frequency, and Guideline-Based Management.” Therapeutic Advances Medical Oncology, vol. 2, 2010, pp. 51–63.

    Measure Specifications




    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-534)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

    Measure Specifications

    Summary of NQF Endorsement Review




    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-533)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Clostridium difficile is responsible for a spectrum of C. difficile infections (CDI), including uncomplicated diarrhea, pseudomembranous colitis, and toxic megacolon, which can, in some instances lead to sepsis and even death. In recent years, a previously unrecognized strain of C. difficile, with increased virulence and high levels of antimicrobial resistance, has resulted in outbreaks in healthcare facilities in the United States. Additionally, CDI has become more common in the community setting, with increased risk in those with history of recent inpatient stay in a healthcare facility. Significant increases in cost of inpatient care have been seen in cases of CDI.

    Measure Specifications

    Summary of NQF Endorsement Review




    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-532)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Clinical guidelines for the management of multidrug resistant organisms (MDROs), including MRSA, have been published. Adherence to the recommendations in the guidelines can result in decreased rates of MDRO transmission and infection. Decreasing rates of infection will result in a lower SIR, which indicates improving performance.

    Measure Specifications

    Summary of NQF Endorsement Review




    Oncology: Radiation Dose Limits to Normal Tissues (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-946)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    This measure is rated as moderate by the measure developer. The quality of the body of evidence supporting the guideline recommendation is summarized according to the National Comprehensive Cancer Network (NCCN) categories of evidence and consensus as being based on "lower-level evidence". Lower-level evidence is later described as evidence that may include non-randomized trials; case series; or when other data are lacking, the clinical experience of expert physicians. Although there is no explicit statement regarding the overall consistency of results across studies in the guidelines supporting the measure, the recommendation received uniform NCCN consensus that the intervention is appropriate. The description of the evidence review in the guideline did not address the overall quantity of studies in the body of evidence. However, 330 articles are cited in NCCN´s pancreatic adenocarcinoma guideline. 408 and 172 articles are cited in NCCN´S non small cell lung cancer and small cell lung cancer guidelines, respectively. A panel of experts with members from each of the NCCN Member Institutions develops the NCCN Guidelines. Specialties that must be included on a particular panel are identified before that panel is convened but also evolve as the standard of care changes over time. This multidisciplinary representation varies from panel to panel. The NCCN Guidelines Panel Chairs are charged with ensuring that representatives of all treatment strategies are included. Many of the panels also include a patient representative, especially when issues of long-term care and patient preference are paramount in the panel´s considerations.

    Measure Specifications

    Summary of NQF Endorsement Review




    Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-527)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    During a Skilled Nursing Facility (SNF) stay, the goals of treatment include fostering the patient’s ability to manage his or her daily activities so that the patient can complete self-care and mobility activities as independently as possible and if feasible, return to a safe, active and productive life in a community-based setting. Previous research has found direct relationships between increased intense therapy services and improved functional outcomes in the SNF setting. Jette et. al (2005) found that higher physical and occupational therapy intensities were associated with greater odds of improving by at least 1 stage in the mobility and activities of daily living functional independence across each condition including patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions. Similarly, a randomized control trial, of 26 SNF patients compared higher intensity rehabilitation to the standard-of-care found greater improvement for mobility activities including gait speed, longer walking distances, and a trend for improvement for self-care activities as measured by the Barthel index (Lenze et. al 2012). The mobility and self-care quality measures will standardize the collection of functional status data, which can improve communication when patients are transferred between providers. Most SNF patients receive care in an acute care hospital prior to the SNF stay, and many SNF patients receive care from another provider after the SNF stay. Use of standardized clinical data to describe a patient´s status across providers can facilitate communication across providers. In describing the importance of functional status, the National Committee on Vital and Health Statistics Subcommittee on Health (2001) noted, “Information on functional status is becoming increasing essential for fostering healthy people and a healthy population. Achieving optimal health and well-being for Americans requires an understanding across the life space of the effects of people’s health conditions on their ability to do basic activities and participate in life situations, in other words, their functional status.” This quality measure will inform SNF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function. Jette, D. U., R. L. Warren, & C. Wirtalla. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 373-9. Lenze, E. J., Host, H. H., Hildebrand M. W., Morrow-Howell, N., Carpenter, B., Freedland, K. E., … Binder, E, F. (2012). Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial. Journal of the American Medical Directors Association. 13(8):708-12. National Committee on Vital and Health Statistics Subcommittee on Health. Classifying and Reporting Functional Status. 2001. Retrieved from http://www.ncvhs.hhs.gov/010617rp.pdf

    Measure Specifications

    Summary of NQF Endorsement Review




    Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-236)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    During a Skilled Nursing Facility (SNF) stay, the goals of treatment include fostering the patient’s ability to manage his or her daily activities so that the patient can complete self-care and mobility activities as independently as possible and if feasible, return to a safe, active and productive life in a community-based setting. Previous research has found direct relationships between increased intense therapy services and improved functional outcomes in the SNF setting. Jette et. al (2005) found that higher physical and occupational therapy intensities were associated with greater odds of improving by at least 1 stage in the mobility and activities of daily living functional independence across each condition including patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions. Similarly, a randomized control trial, of 26 SNF patients compared higher intensity rehabilitation to the standard-of-care found greater improvement for mobility activities including gait speed, longer walking distances, and a trend for improvement for self-care activities as measured by the Barthel index (Lenze et. al 2012). The mobility and self-care quality measures will standardize the collection of functional status data, which can improve communication when patients are transferred between providers. Most SNF patients receive care in an acute care hospital prior to the SNF stay, and many SNF patients receive care from another provider after the SNF stay. Use of standardized clinical data to describe a patient´s status across providers can facilitate communication across providers. In describing the importance of functional status, the National Committee on Vital and Health Statistics Subcommittee on Health (2001) noted, “Information on functional status is becoming increasing essential for fostering healthy people and a healthy population. Achieving optimal health and well-being for Americans requires an understanding across the life space of the effects of people’s health conditions on their ability to do basic activities and participate in life situations, in other words, their functional status.” This quality measure will inform SNF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function. Jette, D. U., R. L. Warren, & C. Wirtalla. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 373-9. Lenze, E. J., Host, H. H., Hildebrand M. W., Morrow-Howell, N., Carpenter, B., Freedland, K. E., … Binder, E, F. (2012). Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial. Journal of the American Medical Directors Association. 13(8):708-12. National Committee on Vital and Health Statistics Subcommittee on Health. Classifying and Reporting Functional Status. 2001. Retrieved from http://www.ncvhs.hhs.gov/010617rp.pdf

    Measure Specifications

    Summary of NQF Endorsement Review




    Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-529)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    During a Skilled Nursing Facility (SNF) stay, the goals of treatment include fostering the patient’s ability to manage his or her daily activities so that the patient can complete self-care and mobility activities as independently as possible and if feasible, return to a safe, active and productive life in a community-based setting. Previous research has found direct relationships between increased intense therapy services and improved functional outcomes in the SNF setting. Jette et. al (2005) found that higher physical and occupational therapy intensities were associated with greater odds of improving by at least 1 stage in the mobility and activities of daily living functional independence across each condition including patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions. Similarly, a randomized control trial, of 26 SNF patients compared higher intensity rehabilitation to the standard-of-care found greater improvement for mobility activities including gait speed, longer walking distances, and a trend for improvement for self-care activities as measured by the Barthel index (Lenze et. al 2012). The mobility and self-care quality measures will standardize the collection of functional status data, which can improve communication when patients are transferred between providers. Most SNF patients receive care in an acute care hospital prior to the SNF stay, and many SNF patients receive care from another provider after the SNF stay. Use of standardized clinical data to describe a patient´s status across providers can facilitate communication across providers. In describing the importance of functional status, the National Committee on Vital and Health Statistics Subcommittee on Health (2001) noted, “Information on functional status is becoming increasing essential for fostering healthy people and a healthy population. Achieving optimal health and well-being for Americans requires an understanding across the life space of the effects of people’s health conditions on their ability to do basic activities and participate in life situations, in other words, their functional status.” This quality measure will inform SNF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function. Jette, D. U., R. L. Warren, & C. Wirtalla. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 373-9. Lenze, E. J., Host, H. H., Hildebrand M. W., Morrow-Howell, N., Carpenter, B., Freedland, K. E., … Binder, E, F. (2012). Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial. Journal of the American Medical Directors Association. 13(8):708-12. National Committee on Vital and Health Statistics Subcommittee on Health. Classifying and Reporting Functional Status. 2001. Retrieved from http://www.ncvhs.hhs.gov/010617rp.pdf

    Measure Specifications

    Summary of NQF Endorsement Review




    Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-528)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    During a Skilled Nursing Facility (SNF) stay, the goals of treatment include fostering the patient’s ability to manage his or her daily activities so that the patient can complete self-care and mobility activities as independently as possible and if feasible, return to a safe, active and productive life in a community-based setting. Previous research has found direct relationships between increased intense therapy services and improved functional outcomes in the SNF setting. Jette et. al (2005) found that higher physical and occupational therapy intensities were associated with greater odds of improving by at least 1 stage in the mobility and activities of daily living functional independence across each condition including patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions. Similarly, a randomized control trial, of 26 SNF patients compared higher intensity rehabilitation to the standard-of-care found greater improvement for mobility activities including gait speed, longer walking distances, and a trend for improvement for self-care activities as measured by the Barthel index (Lenze et. al 2012). The mobility and self-care quality measures will standardize the collection of functional status data, which can improve communication when patients are transferred between providers. Most SNF patients receive care in an acute care hospital prior to the SNF stay, and many SNF patients receive care from another provider after the SNF stay. Use of standardized clinical data to describe a patient´s status across providers can facilitate communication across providers. In describing the importance of functional status, the National Committee on Vital and Health Statistics Subcommittee on Health (2001) noted, “Information on functional status is becoming increasing essential for fostering healthy people and a healthy population. Achieving optimal health and well-being for Americans requires an understanding across the life space of the effects of people’s health conditions on their ability to do basic activities and participate in life situations, in other words, their functional status.” This quality measure will inform SNF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function. Jette, D. U., R. L. Warren, & C. Wirtalla. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 373-9. Lenze, E. J., Host, H. H., Hildebrand M. W., Morrow-Howell, N., Carpenter, B., Freedland, K. E., … Binder, E, F. (2012). Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial. Journal of the American Medical Directors Association. 13(8):708-12. National Committee on Vital and Health Statistics Subcommittee on Health. Classifying and Reporting Functional Status. 2001. Retrieved from http://www.ncvhs.hhs.gov/010617rp.pdf

    Measure Specifications

    Summary of NQF Endorsement Review




    Discharge to Community-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-462)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The ultimate goals of post-acute care are avoiding institutionalization and returning patients to their previous level of independence and functioning, with discharge to community being the primary goal for the majority of post-acute patients. For many, home is a symbol of independence, privacy, and competence. Discharge to community is considered a valuable outcome to measure because it is a multifaceted measure that captures the patient’s functional status, cognitive capacity, physical ability, and availability of social support at home. There is considerable variation in discharge to community rates within and across post-acute settings. Studies show geographic variation, variation across patient socioeconomic characteristics (for example, race and ethnicity), and variation by facility characteristics (for profit vs. nonprofit, freestanding vs. hospital-based, urban vs. rural). In the IRF setting, discharge to community rates vary across providers, ranging from about 60% to 75%. The 2015 MedPAC report shows that, in FY 2013, the facility-level, mean risk-adjusted discharge to community rate for IRFs within 100 days of admission was 75.8%, and the mean observed rate was 74.7%. Discharge to community rates also vary widely in the SNF setting, ranging from as low as 31% to as high as 65%. The 2015 MedPAC report shows a mean risk-adjusted discharge to community rate of 37.5% for SNFs within 100 days of admission, and mean observed rate of 40.1%. A multicenter study of 23 LTCHs reported that only 28.8% of 1,061 patients who were ventilator-dependent on admission were discharged to home or assisted living facility. A study of 66,510 Medicare beneficiaries during pre- and post-HH episodes, revealed that 64 percent of beneficiaries discharged from HH did not use any other Medicare-reimbursed acute or post-acute services in the 30 days following HH discharge. Significant numbers of patients were admitted to inpatient facilities (29 percent) and lesser numbers to skilled nursing facilities (7.6 percent), inpatient rehabilitation (1.5 percent) and home health (7.2 percent) or hospice (3.3 percent) within 30 days of HH discharge (Wolff et al., 2008).

    Measure Specifications




    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1130)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medication review in post-acute care is generally considered to include medication reconciliation for all medications and medication review for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and medication review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    (New information provided by CMS on January 19, 2016) Medication review in post-acute care is generally considered to include medication reconciliation and drug regimen review for all medications and for what poses as potential clinically significant medication issues for the patient/resident. As a process measure, medication reconciliation and drug regimen review for potential clinically significant medication issues are expected to reduce re-hospitalizations, reduce adverse events related to medications and improve health outcomes.

    Measure Specifications




    Medicare Spending per Beneficiary-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-291)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Medicare payments to PAC have grown at a consistently higher rate than other major Medicare sectors. Between 2001 and 2013, Medicare PAC spending grew at an annual rate of 6.1 percent and doubled to $59.4 billion.

    Measure Specifications




    Percent of Skilled Nursing Facility Residents Who Newly Received an Antipsychotic Medication (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1133)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Antipsychotic medications can be potentially dangerous for the elderly, especially for those who do not have the clinical indication. Of particular concern is the off-label use of these drugs for elders with dementia or dementia-related psychoses or agitation (Jeste et al., 2008). In April 2005, the FDA issued a black box warning against prescribing atypical antipsychotic medications for elderly with dementia (Rosack, 2005). The evidence on which the black box warning was based came from a meta-analysis of data from 17 randomized trials with a total of 5,106 patients which identified an “approximately 1.6- to 1.7-fold increase in mortality in the combined studies” (Rosack, 2005). In June 2008, the FDA extended the warning to all categories of antipsychotic drugs, conventional as well as atypical (Rosack, 2005). In this warning, the FDA advised health care professionals, "Antipsychotics are not indicated for the treatment of dementia-related psychosis." Besides elevated mortality risk, clinical trials of atypical antipsychotic medications also show elevated risk for serious adverse events including falls, somnolence and abnormal gait (Rosack, 2005; FDA, 2008; Ballard & Margallo-Lana, 2004; Martin et al., 2003; Neil, Curran, and Wattis, 2003; Doody et al., 2001; Jackson-Siegal, 2004). Additionally, there is evidence of increased risk for cerebrovascular adverse events associated with certain atypical antipsychotic medications (e.g., risperidone, olanzapine, and aripiprazole) (Jeste et al., 2008). While the black box warnings applied to all antipsychotic medications, a recent study identified some differences in mortality risk by medication and dose among a large population based cohort of dually-eligible nursing home residents prescribed antipsychotic medications (Huybrechts et al., 2012). In addition to being a threat to patient safety, antipsychotic medications are also expensive to consumers and Medicare. Atypical antipsychotic drugs cost more than $13 billion in 2007, "nearly 5 percent of all U.S. drug expenditures" (Alexander et al., 2011). They are also responsible for a significant portion of expenditures for Medicare Part D (Doody et al., 2001). Furthermore, the OIG report found that 51% of Medicare atypical antipsychotic drug claims for elderly nursing home residents were erroneous, amounting to $116 million. (OIG, 2011). Use of this measure should prompt nursing facilities to re-examine their prescribing patterns which may result in practice consistent with clinical recommendations and guidelines. Reference: Alexander, G., Gallagher, S., Mascola, A., et al.: Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf 20(2):177-184, 2011. Ballard, C.G., and Margallo-Lana, M.L.: The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. J Clin Psychiatry 65 Suppl 11:23-28, 2004. Doody, R.S., Stevens, J.C., Beck, C., et al.: Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 56(9):1154-1166, 2001. FDA: Information for Healthcare Professionals: Conventional Antipsychotics. FDA Alert (June 16, 2008). http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm124830.htm Huybrechts, K.F., Gerhard, T., Crystal, S., et al.: Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ 344:e977, 2012. Jackson-Siegal, J.M., Schneider, L.S., Baskys, A., et al.: Recognizing and responding to atypical antipsychotic side effects. J Am Med Dir Assoc 5(4 Suppl):H7-10, 2004. Jeste, D.V., Blazer, D., Casey, D., et al.: ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 33(5):957-970, 2008. Martin, H., Slyk, M.P., Deymann, S., et al.: Safety profile assessment of risperidone and olanzapine in long-term care patients with dementia. J Am Med Dir Assoc 4(4):183-188, 2003. Neil, W., Curran, S., and Wattis, J.: Antipsychotic prescribing in older people. Age Ageing 32(5):475-483, 2003. Office of Inspector General (OIG): Medicare Atypical Antipsychotic Drug Claims For Elderly Nursing Home Residents, 2011. Rosack, J.: FDA orders new warning on atypical antipsychotics. Psychiatr News 40(9):1-50, 2005."

    Measure Specifications




    Percent of Skilled Nursing Facility Residents Who Self-Report Moderate to Severe Pain (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1131)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    The opportunity for improving unrelieved pain in nursing home residents continues to be demonstrated by reports of less-than-optimal pain management, considerable variation in pain management, and data from interventions aimed at improving pain management in nursing homes. In 2011, a report from the Institute of Medicine stated, “evidence indicates that nursing homes undertreat pain, especially in cognitively impaired and minority residents” (Institute of Medicine, 2011). Recent reports indicate that pain management in nursing home can be improved by improving pain assessment, including use of structured assessment tools. Investigations of pain management strategies have increasingly broadened to include comprehensive approaches that are evidence based, multidisciplinary, and use behavioral approaches to educate and train staff (Cervo, et al., 2012; Savvas et al., 2014). Comprehensive interventions attempt to improve both pain assessment and pain treatment by adopting pain-assessment tools and pain-management clinical guidelines. Pain management may also be improved by nonpharmacological approaches to pain management, such as cognitive behavioral therapy, mindfulness meditation, relaxation techniques, assistive devices, physical activity and exercise, and complementary therapies. (Abdulla et al., 2013). References: 1. Abdulla, A., Adams, N., Bone, M., Elliott, A. M., Gaffin, J., Jones, D., et al. (2013). Guidance on the management of pain in older people. Age and Ageing, 42 Suppl 1, i1-57. 2. Cervo, F. A., Bruckenthal, P., Fields, S., Bright-Long, L. E., Chen, J. J., Zhang, G., et al. (2012). The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia. Geriatric Nursing (New York, NY), 33(6), 430-438. 3. Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: National Academics Press. 4. Savvas, S. M., Toye, C. M., Beattie, E. R., & Gibson, S. J. (2014). An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities. Journal of the American Geriatrics Society, 62(8), 1583-1589.

    Measure Specifications

    Summary of NQF Endorsement Review




    Percent of Skilled Nursing Facility Residents Who Were Assessed and Appropriately Given the Influenza Vaccine (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1132)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Influenza and pneumonia are now reported as the fifth-leading cause of death among people aged 65 or older in the United States (CMS, 2011). As of 2011, there are over 200,000 hospitalizations from influenza, on average, every year (CMS, 2011). An average of 36,000 Americans die annually due to influenza and its complications and most are people 65 years old and over (CMS, 2011). Vaccination can be cost-effective and successful in preventing influenza. A study conducted in 2002 by Nichol and Goodman found that vaccination of healthy elderly was associated with a 36% reduction in hospitalization for pneumonia or influenza, an 18% reduction in hospitalization for all respiratory conditions, and a 40% reduction in mortality. (Nichol and Goodman, 2002) Influenza vaccination was also associated with cost savings. (Nichol and Goodman, 2002). Influenza vaccination is recommended for those over 65 years old and those with medical conditions, which describes the population of post-acute care facilities, making it an appropriate quality measure for skilled nursing facilities. By focusing on skilled nursing facility residents during the influenza season, publicly reporting this measure will increase vaccination during that time period and prevent influenza outbreaks in skilled nursing facilities. References: 1. Centers for Medicare & Medicaid Services (2011, May). Adult immunization: overview. Retrieved from https://www.cms.gov/adultImmunizations/ 2. Nichol KL, Goodman M., Cost effectiveness of influenza vaccination for healthy persons between ages 65 and 74 years. Vaccine. 2002 May 15;20(Suppl 2):S21-4.

    Measure Specifications

    Summary of NQF Endorsement Review




    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-495)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Hospital readmissions of Medicare beneficiaries discharged from a hospital to a skilled nursing facility (SNF) are prevalent and expensive, and prior studies suggest that a large proportion of readmissions are preventable (Mor et al., 2010). According to Mor et al., based an analysis of SNF data from 2006 Medicare claims merged with the Minimum Data Set (MDS), 23.5 percent of SNF stays resulted in a rehospitalization within 30 days of the initial hospital discharge. The average Medicare payment for each readmission was $10,352 per hospitalization, for a total of $4.34 billion. Of these rehospitalizations, 78 percent were deemed potentially avoidable, and applying this figure to the aggregate cost indicates that avoidable hospitalizations resulted in an excess cost of $3.39 billion (78 percent of $4.34 billion) to Medicare (Mor, Intrator, Feng, et al., 2010). Several analyses of hospital readmissions of SNF patients suggest there is opportunity for reducing hospital readmissions among SNF patients (Li et al., 2012; Mor et al., 2010), and multiple studies suggest SNF structural and process characteristics that impact readmission rates (Coleman et al., 2004; MedPAC 2011).

    Measure Specifications




    Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) (required by PAMA) (Program: Skilled Nursing Facility Value-Based Purchasing Program; MUC ID: MUC15-1048)

    Summary of Workgroup Deliberations

    Rationale for measure provided by HHS
    Hospital readmissions of Medicare beneficiaries discharged from a hospital to a SNF are prevalent and expensive, and prior studies suggest that a large proportion of readmissions are preventable (Mor et al., 2010). According to Mor et al., based an analysis of SNF data from 2006 Medicare claims merged with the Minimum Data Set (MDS), 23.5 percent of SNF stays resulted in a rehospitalization within 30 days of the initial hospital discharge. The average Medicare payment for each readmission was $10,352 per hospitalization, for a total of $4.34 billion. Of these rehospitalizations, 78 percent were deemed potentially avoidable, and applying this figure to the aggregate cost indicates that avoidable hospitalizations resulted in an excess cost of $3.39 billion (78 percent of $4.34 billion) to Medicare (Mor, Intrator, Feng, et al., 2010). Several analyses of hospital readmissions of SNF patients suggest there is opportunity for reducing hospital readmissions among SNF patients (Li et al., 2012; Mor et al., 2010), and multiple studies suggest SNF structural and process characteristics that impact readmission rates (Coleman et al., 2004; MedPAC 2011).

    Measure Specifications




    Appendix B: Program Summaries

     The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program Index


    Full Program Summaries

    Home Health Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Home Health Quality Reporting Program (HH QRP) was established in accordance with section 1895 (b)(3)(B)(v)(II) of the Social Security Act. Home Health Agencies (HHAs) are required by the Act to submit quality data for use in evaluating quality for Home Health agencies. Section 1895(b) (3)(B)(v)(I) of the Act also requires that HHAs that do not submit quality data to the Secretary be subject to a 2 percent reduction in the annual payment update, effective in calendar year 2007 and every subsequent year. Data sources for the HH QRP include the Outcome and Assessment Information Set (OASIS) and Medicare FFS claims. Data is publically reported on the Home Health Compare website. The HH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups.

    Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

    High Priority Domains for Future Measure Consideration: CMS identified the following domains as high-priority for future measure consideration:

    1. Patient and Family Engagement: Quality care in home health settings should addressed not only assessing for what the patient/family desires, but also to assess how well care is provided and what services are offered to meet an individual’s care preferences.
    2. Patient and Family Engagement: Functional status and functional decline are important to assess for individuals who reside in a home-based setting. Individuals who receive care in home-based settings may have functional limitations and may be at risk for further decline in function due to limited mobility and ambulation. Therefore, measures to assess functional status are in development.
    3. Making Care Safer: Safety for individuals in a home-based setting is an important priority for the HH QRP as persons in home health settings are at risk for major injury due to falls, new or worsened pressure ulcers, pain, and functional decline. Therefore, these concepts will be considered for future measure development.
    4. Making Care Affordable: An important consideration for the HH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
    5. Communication/Care Coordination: Assessing an individual’s care transitions and rehospitalizations is important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
    6. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the HH QRP. Therefore, a medication reconciliation quality measure for individuals in a home health setting is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospice Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Hospice Quality Reporting Program (HQRP) was established in accordance with section 1814(i) of the Social Security Act, as amended by section 3004(c) of the Affordable Care Act. The HQRP applies to all hospices, regardless of setting. Proposed data sources for future HQRP measures include the Hospice Item Set and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaire. HQRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, Hospices that fail to submit quality data will be subject to a 2.0 percentage point reduction to their annual payment update.

    High Priority Domains for Future Measure Consideration: CMS identified the following domains as high-priority for Hospice QRP future measure consideration:

    1. Overall goal HQRP: Symptom Management Outcome Measures. There is a lack of tested and endorsed outcome measures for hospice across domains of hospice care, including symptom management (e.g.; physical and other symptoms). Developing and implementing outcome measures for hospice is important for providers, patients and families, and other stakeholders because symptom management is a central aspect of hospice care.
    2. Communication/Care Coordination and/or Patient and Family Engagement: Patient preference for care is difficult to measure at end of life when patients may or may not be able to state their preferences, and may have changes in their preferences. However, a central tenet of hospice care is responsiveness to patient and family care preferences; as much as possible, patient preferences should be incorporated into new measure development.
    3. Patient and Family Engagement: Measurement of goal attainment is naturally linked to determining patient/family preferences. Quality care in hospice should address not only establishing what the patient/family desires but also providing care and services in line with those preferences.
    4. Making Care Safer: Timeliness/responsiveness of care. While timeliness of referral to hospice is not within a hospices’ control, hospice initiation of treatment once a patient has elected the hospice benefit is under the control of the hospice. Responsiveness of the hospice during times of patient or family need is an important indicator about hospice services for consumers in particular.
    5. Communication/Care Coordination: Measurement of care coordination is integral to the provision of quality care and should be aligned across care settings.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Inpatient Rehabilitation Facility Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs) was established in accordance with section 1886(j) of the Social Security Act as amended by section 3004(b) of the Affordable Care Act. The IRF QRP applies to all IRF facilities that receive the IRF PPS (e.g., IRF hospitals, IRF units that are co-located with affiliated acute care facilities, and IRF units affiliated with critical access hospitals [CAHs]). Data sources for IRF QRP measures include Medicare FFS claims, the Center for Disease Control’s National Health Safety Network (CDC NHSN) data submissions, and Inpatient Rehabilitation Facility - Patient Assessment instrument (IRF-PAI) records. The IRF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, IRFs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable IRF Prospective Payment System (PPS) payment update. Plans for future public reporting of IRF QRP measures are under development.

    Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

    High Priority Domains for Future Measure Consideration: CMS identified the following four domains as high-priority for future measure consideration:

    1. Making Care Safer (subdomains: hospital-acquired infections and hospital-acquired conditions): Patient safety is an important priority domain for the IRF QRP as IRF patients are at risk for injury due to falls, new or worsened pressure ulcers and infections such as CAUTI, C. Diff. and MRSA.
    2. Patient and Family Engagement: A primary focus of IRF care is restoring functional status. Metrics showing change in self-care and mobility function and discharge self-care and mobility are under development. Metric for achievement of functional status goals such as discharge to community. In addition, the experiences of patients and caregivers are important to measure and are important priority for the IRF QRP.
    3. Making Care Affordable: An important consideration for the IRF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
    4. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
    5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the IRF QRP. Therefore, a medication reconciliation quality measure for IRF patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Long-Term Care Hospital Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) was established in accordance with section 1886(m) of the Social Security Act, as amended by Section 3004(a) of the Affordable Care Act. The LTCH QRP applies to all LTCHs facilities designated as an LTCH under the Medicare program. Data sources for LTCH QRP measures include Medicare FFS claims, the Center for Disease Control and Prevention’s National Health Safety Network (CDC’s NHSN) data submissions, and the LTCH Continuity Assessment Record and Evaluation Data Sets (LCDS). The LTCH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, LTCHs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable Prospective Payment System (PPS) increase factor.

    Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

    High Priority Domains for Future Measure Consideration: CMS identified the following domains as high-priority for LTCH QRP future measure consideration:

    1. Effective Prevention and Treatment: Having measures related to ventilator use, ventilator-associated event and ventilator weaning rate are a high priority for CMS as prolonged mechanical ventilator use is quite common in LTCHs and respiratory diagnosis with ventilator support for 96 or more hours is the most frequently occurring diagnosis.
    2. Effective Prevention and Treatment (Aim: Healthy People/Healthy Communities): In discussions with LTCH providers, it was noted that mental health status is an important measure of care for LTCH patients. CMS is considering a Depression Assessment & Management quality measure.
    3. Patient and Family Engagement: While rehabilitation and restoring functional status are not the primary goals of patient care in the LTCH setting, functional outcomes remain an important indicator of LTCH quality as well as key to LTCH care trajectories. Providers must be able to provide functional support to patients with impairments. Thus, metrics showing change in self-care and mobility function are under development.
    4. Patient and Family Engagement: CMS would like to explore measures that will evaluate the patient’s experiences of care as this is a high priority of providers. Therefore, the HCAHPS and Care Transition quality measure (CTM)-3 is being considered.
    5. Making Care Affordable: An important consideration for the LTCH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
    6. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
    7. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the LTCH QRP. Therefore, a medication reconciliation quality measure for LTCH patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Skilled Nursing Facility Quality Reporting System 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Improving Medicare Post-Acute Care Transitions Act of 2014 (The IMPACT Act) added Section 1899B to the Social Security Act establishing the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). Facilities that submit data under the SNF PPS are required to participate in the SNF QRP, excluding units that are affiliated with critical access hospitals (CAHs). Data sources for SNF QRP measures include Medicare FFS claims as well as Minimum Data Set (MDS) assessment data. The SNF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2018, providers that fail to submit required quality data to CMS will have their annual updates reduced by 2.0 percentage points.

    Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

    High Priority Domains for Future Measure Consideration: CMS identified the following four domains as high-priority for future measure consideration:

    1. Patient and Family Engagement: Functional status and functional decline are important to assess for residents in SNF settings. Residents who receive care while in a SNF may have functional limitations and may be at risk for further decline in function due to limited mobility and ambulation. Therefore, measures to assess functional status are in development.
    2. Making Care Safer: Resident safety is an important priority domain for the SNF QRP as persons in SNF settings are at risk for major injury due to falls, new or worsened pressure ulcers, pain, and functional decline. Therefore, these concepts will be considered for future measure development.
    3. Making Care Affordable: An important consideration for the SNF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
    4. Communication/Care Coordination: Assessing resident care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
    5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the SNF QRP. Therefore, a medication reconciliation quality measure for SNF residents is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Skilled Nursing Facility Value-Based Purchasing Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Skilled Nursing Facility Value-Based Purchasing (SNF-VBP) Program was established by Section 215 (b)of the Protecting Access to Medicare Act of 2014. The facility adjusted Federal per diem rate will be reduced by 2% and an incentive payment will then be applied to facilities based upon readmission measure performance.

    The legislation mandates that CMS will specify a SNF all-cause all-condition hospital readmission measure by no later than October 1, 2015. It further requires that a resource use measure that reflects resource use by measuring all-condition risk-adjusted potentially preventable hospital readmission rates for SNFs will be specified no later than October 1, 2016 and replace the all-cause all-condition measure as soon as is practicable.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. The sole measure requirement at this time is the specification of a potentially preventable readmission measure. CMS lacks the authority to implement additional measures beyond the two described in the statute.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the SNF-VBP program. At a minimum, the following requirements must be met for selection in the SNF-VBP program:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Ambulatory Surgical Center Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Ambulatory Surgical Center (ASC) Quality Reporting Program was established under the authority provided by Section 109(b) of the Medicare Improvements and Extension Act of 2006, Division B, Title I of the Tax Relief and Health Care Act (TRHCA) of 2006. The statute provides the authority for requiring ASCs paid under the ASC fee schedule (ASCFS) to report on process, structure, outcomes, patient experience of care, efficiency, and costs of care measures. ASCs receive a 2.0 percentage point payment penalty to their ASCFS annual payment update for not meeting program requirements. CMS implemented this program so that payment determinations were effective beginning with the Calendar Year (CY) 2014 payment update.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Making Care Safer
      1. Measures of infection rates
    2. Person and Family Engagement
      1. Measures that improve experience of care for patients, caregivers, and families.
      2. Measures to promote patient self-management.
    3. Best Practice of Healthy Living
      1. Measures to increase appropriate use of screening and prevention services.
      2. Measures which will improve the quality of care for patients with multiple chronic conditions.
      3. Measures to improve behavioral health access and quality of care.
    4. Effective Prevention and Treatment
      1. Surgical outcome measures
    5. Communication/Care Coordination
      1. Measures to embed best practice to manage transitions across practice settings.
      2. Measures to enable effective health care system navigation.
      3. To reduce unexpected hospital/emergency visits and admissions.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the ASCQR program.
    At a minimum, the following requirements will be considered in selecting measures for ASCQR Program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    4. Measure must be field tested for the ASC clinical setting.
    5. Measure that is clinically useful.
    6. Reporting of measure limits data collection and submission burden since many ASCs are small facilities with limited staffing.
    7. Measure must supply sufficient case numbers for differentiation of ASC performance.
    8. Measure must promote alignment across HHS and CMS programs.
    9. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    End-Stage Renal Disease Quality Incentive Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: For more than 30 years, monitoring the quality of care provided to end-stage renal disease (ESRD) patients by dialysis facilities has been an important component of the Medicare ESRD payment system. The ESRD quality incentive program (QIP) is the most recent step in fostering improved patient outcomes by establishing incentives for dialysis facilities to meet or exceed performance standards established by CMS. The ESRD QIP is authorized by section 1881(h) of the Social Security Act, which was added by section 153(c) of Medicare Improvements for Patients and Providers (MIPPA) Act (the Act). CMS established the ESRD QIP for Payment Year (PY) 2012, the initial year of the program in which payment reductions were applied, in two rules published in the Federal Register on August 12, 2010, and January 5, 2011 (75 FR 49030 and 76 FR 628, respectively). Subsequently, CMS published rules in the Federal Register detailing the QIP requirements for PY 2013 through FY 2016. Most recently, CMS published a rule on November 6, 2014 in the Federal Register (79 FR 66119), providing the QIP requirements for PY2017 and PY 2018, with the intention of providing an additional year between finalization of the rule and implementation in future rules.

    Section 1881(h) of the Act requires the Secretary to establish an ESRD QIP by (i) selecting measures; (ii) establishing the performance standards that apply to the individual measures; (iii) specifying a performance period with respect to a year; (iv) developing a methodology for assessing the total performance of each facility based on the performance standards with respect to the measures for a performance period; and (v) applying an appropriate payment reduction to facilities that do not meet or exceed the established Total Performance Score (TPS).

    High Priority Domains for Future Measure Consideration: CMS identified the following 3 domains as high-priority for future measure consideration:

    1. Care Coordination: ESRD patients constitute a vulnerable population that depends on a large quantity and variety medication and frequent utilization of multiple providers, suggesting medication reconciliation is a critical issue. Dialysis facilities also play a substantial role in preparing dialysis patients for kidney transplants, and coordination of dialysis-related services among transient patients has consequences for a non-trivial proportion of the ESRD dialysis population.
    2. Safety: ESRD patients are frequently immune-compromised, and experience high rates of blood stream infections, vascular access-related infections, and mortality. Additionally, some medications provided to treat ESRD patients may cause harmful side effects such as heart disease and a dynamic bone disease. Recently, oral-only medications were excluded from the bundle payment, increasing need for quality measures that protect against overutilization of oral-only medications.
    3. Patient- and Caregiver-Centered Experience of Care: Sustaining and recovering patient quality of life was among the original goals of the Medicare ESRD program. This includes such issues as physical function, independence, and cognition. Quality of Life measures should also consider the life goals of the particular patient where feasible, to the point of including Patient-Reported Outcomes.

    Measure Requirements:

    1. Measures for anemia management reflecting FDA labeling, as well as measures for dialysis adequacy.
    2. Measure(s) of patient satisfaction, to the extent feasible.
    3. Measures of iron management, bone mineral metabolism, and vascular access, to the extent feasible.
    4. Measures should be NQF endorsed, save where due consideration is given to endorsed measures of the same specified area or medical topic.
    5. Must include measures considering unique treatment needs of children and young adults.
    6. May incorporate Medicare claims and/or CROWNWeb data, alternative data sources will be considered dependent upon available infrastructure.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Acquired Condition Reduction Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: Section 3008 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program (HAC Reduction Program). Created under Section 1886(p) of the Social Security Act (the Act), the HAC Reduction Program provides an incentive for hospitals to reduce the number of HACs. Effective Fiscal Year (FY) 2014 and beyond, the HAC Reduction Program requires the Secretary to make payment adjustments to applicable hospitals that rank in the top quartile of all subsection (d) hospitals relative to a national average of HACs acquired during an applicable hospital stay. HACs include a condition identified in subsection 1886(d)(4)(D)(iv) of the Act and any other condition determined appropriate by the Secretary. Section 1886(p)(6)(C) of the Act requires the HAC information be posted on the Hospital Compare website.

    CMS finalized in the FY 2014 IPPS/LTCH PPS final rule that hospitals will be scored using a Total HAC Score based on measures categorized into two (2) domains of care, each with a different set of measures. Domain 1 consists of Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), and Domain 2 consists of Hospital Associated Infections (HAI) as collected by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Both domains of the HAC Reduction Program are categorized under the National Quality Strategy (NQS) priority of “Making Care Safer”. Measures in each domain are assigned points so that each domain has a score. In the FY 2016 IPPS/LTCH PPS proposed rule, we are proposing that the weighting of the domain scores be changed as follows for the FY 2017 program: (1) Domain 1 weight would be decreased from 25% to 15%; and (2) Domain 2 weight would be increased from 75% to 85%. The Total HAC Score is the sum of the two weighted domain scores.

    High Priority Domains for Future Measure Consideration: For FY 2017 federal rulemaking, CMS may propose the adoption, removal, and/or suspension of measures for fiscal years 2018 and beyond of the HAC Reduction Program. CMS identified the following topics as areas within the NQS priority of “Making Care Safer” for future measure consideration:

    1. Making Care Safer:
      1. Adverse Drug Events
      2. Ventilator Associated Events
      3. Additional Surgical Site Infection Locations
      4. Outcome Risk-Adjusted Measures

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HAC Reduction Program. At a minimum, the following requirements must be met for consideration in the HAC Reduction Program:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Inpatient Quality Reporting and EHR Incentive Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Hospital Inpatient Quality Reporting (IQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and later amended by the Deficit Reduction Act (DRA) of 2005. The program requires hospitals paid under the Inpatient Prospective Payment System (IPPS) to report on process, structure, outcomes, patient perspectives on care, efficiency, and costs of care measures. Hospitals receive a quarter of the applicable percentage point of the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) payment update. Hospitals who choose non-participation in the program receive a reduction by that same amount. Performance of quality measures are publicly reported on the CMS Hospital Compare website.

    The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) amended Titles XVIII and XIX of the Social Security Act (the Act) to authorize incentive payments to eligible hospitals (EHs) and Critical Access Hospitals (CAHs) and other groups eligible to participate in the EHR Incentive Program, to promote the adoption and meaningful use of certified electronic health record (EHR) technology (CEHRT). EHs and CAHs are required to report on electronically specified clinical quality measures (eCQMs) using CEHRT in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive. All EHR Incentive Program requirements related to eCQM reporting will be addressed in IQR Program rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, and information regarding the eCQMs.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement:
      1. Measures that foster the engagement of patients and families as partners in their care.
    2. Best Practices of Healthy Living:
      1. Measures that promote best practices to enable healthy living.
    3. Making Care Affordable:
      1. Measures that effectuate changes in efficiency and reward value over volume.

    CMS identified the following topics/areas as high-priority for future measure consideration:

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IQR program. At a minimum, the following criteria will be considered in selecting measures for IQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must be claims-based or an electronically specified clinical quality measure (eCQM).
      1. A Measure Authoring Tool (MAT) number must be provided for all eCQMs, created in the HQMF format
      2. eCQMs must undergo reliability and validity testing including review of the logic and value sets by the CMS partners, including, but not limited to, MITRE and the National Library of Medicine
      3. eCQMs must have successfully passed feasibility testing
    3. Measure may not require reporting to a proprietary registry.
    4. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    5. Measure must be fully developed, tested, and validated in the acute inpatient setting.
    6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration.
    7. Measure must promote alignment across HHS and CMS programs.
    8. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Outpatient Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Hospital Outpatient Quality Reporting (OQR) Program was established by Section 109 of the Tax Relief and Health Care Act (TRHCA) of 2006. The program requires subsection (d) hospitals providing outpatient services paid under the Outpatient Prospective Payment System (OPPS) to report on process, structure, outcomes, efficiency, costs of care, and patient experience of care. Hospitals receive a 2.0 percentage point reduction of their annual payment update (APU) under the Outpatient Prospective Payment System (OPPS) for non-participation in the program. Performance on quality measures is publicly reported on the CMS Hospital Compare website.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Making Care Safer:
      1. Measures that address processes and outcomes designed to reduce risk in the delivery of health care, e.g., emergency department overcrowding and wait times.
    2. Best Practices of Healthy Living:
      1. Measures that focus on primary prevention of disease or general screening for early detection of disease unrelated to a current or prior condition.
    3. Patient and Family Engagement:
      1. Measures that address engaging both the person and their family in their care.
      2. Measures that address cultural sensitivity, patient decision-making support or care that reflects patient preferences.
    4. Communication/Care Coordination:
      1. Measures to embed best practices to manage transitions across practice settings.
      2. Measures to enable effective health care system navigation.
      3. Measures to reduce unexpected hospital/emergency visits and admissions.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HOQR program. At a minimum, the following criteria will be considered in selecting measures for HOQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    4. Measure must be fully developed, tested, and validated in the hospital outpatient setting.
    5. Measure must promote alignment across HHS and CMS programs.
    6. Feasibility of Implementation: An evaluation of feasibility is based on factors including, but not limited to
      1. The level of burden associated with validating measure data, both for CMS and for the end user.
      2. Whether the identified CMS system for data collection is prepared to accommodate the proposed measure(s) and timeline for collection.
      3. The availability and practicability of measure specifications, e.g., measure specifications in the public domain.
      4. The level of burden the data collection system or methodology poses for an end user.
    7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Readmissions Reduction Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: Section 3025 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital Readmissions Reduction Program (HRRP). Codified under Section 1886(q) of the Social Security Act (the Act), the HRRP provides an incentive for hospitals to reduce the number of excess readmissions that occur in their settings. Effective Fiscal Year (FY) 2012 and beyond, the HRRP requires the Secretary to establish readmission measures for applicable conditions and to calculate an excess readmission ratio for each applicable condition, which will be used to determine a payment adjustment to those hospitals with excess readmissions. A readmission is defined as an admission to an acute care hospital within 30 days of a discharge from the same or another acute care hospital. A hospital’s excess readmission ratio measures a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition. Applicable conditions in the HRRP program currently include measures for acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, and elective total knee and total hip arthroplasty. Readmission following coronary artery bypass graft surgery has been finalized as an applicable condition beginning with the FY 2017 payment determination. Planned readmissions are excluded from the excess readmission calculation.

    High Priority Domains for Future Measure Consideration: For FY 2017 federal rulemaking, CMS may propose the adoption, removal, refinement, and or suspension of measures for fiscal year 2018 and subsequent years of the HRRP. CMS continues to emphasize the importance of the NQS priority of “Communication/Care Coordination” for this program.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HRRP program. At a minimum, the following criteria and requirements must be met for consideration in the HRRP program:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Value-Based Purchasing Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Hospital Value-Based Purchasing (VBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year. The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. However, measures of five conditions (acute myocardial infarction, pneumonia, heart failure, surgeries, and healthcare-associated infections), the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and efficiency measures must be included. Measures are eligible for adoption in the Hospital VBP Program based on the statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare Web site.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement:
      1. Measures that foster the engagement of patients and families as partners in their care.
    2. Best Practices of Healthy Living:
      1. Measures that promote best practices to enable healthy living.
    3. Making Care Affordable:
      1. Measures that effectuate changes in efficiency and reward value over volume.

    CMS identified the following topics/areas as high-priority for future measure consideration:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Inpatient Psychiatric Facility Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program was established by Section 1886(s)(4) of the Social Security Act, as added by sections 3401(f)(4) and 10322(a) of the Patient Protection and Affordable Care Act (the Affordable Care Act). Under current regulations, the program requires participating inpatient psychiatric facilities (IPFs) to report on 10 quality measures or face a 2.0 percentage point reduction to their annual update. Reporting on these measures apply to payment determinations for Fiscal Year (FY) 2016 and beyond. The reporting period for the FY 2016 payment determination was CY 2014, with the exception of the Follow-Up After Hospitalization for Mental Illness measure which was July 1, 2013 – June 30, 2014. Four measures were added for the FY 2017 payment determination, two with reporting periods of October 1, 2015 - March 31, 2016 and two with reporting periods of CY 2015.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement
      1. Patient experience of care
    2. Effective Prevention and Treatment
      1. Inpatient psychiatric treatment and quality of care of geriatric patients and other adults, adolescents, and children
      2. Quality of prescribing for antipsychotics and antidepressants
    3. Communication/Care Coordination
      1. Readmissions and re-hospitalizations
    4. Best Practices of Healthy Living
      1. Screening and treatment for non-psychiatric comorbid conditions for which patients with mental or substance use disorders are at higher risk
      2. Access to care
    5. Making Care Affordable
      1. Measures which effectuate changes in efficiency and that reward value over volume.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IPFQR program. At a minimum, the following criteria will be considered in selecting measures for IPFQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    3. The measure assesses meaningful performance differences between facilities.
    4. The measure addresses an aspect of care affecting a significant proportion of IPF patients.
    5. Measure must be fully developed, tested, and validated in the acute inpatient setting.
    6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    7. Measure must promote alignment across HHS and CMS programs.
    8. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: Section 3005 of the Affordable Care Act added new subsections (a)(1)(W) and (k) to section 1866 of the Social Security Act (the Act). Section 1866(k) of the Act establishes a quality reporting program for hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as a “PPS-Exempt Cancer Hospital” or “PCH”). Section 1866(k)(1) of the Act states that, for FY 2014 and each subsequent fiscal year, a PCH shall submit data to the Secretary in accordance with section 1866(k)(2) of the Act with respect to such a fiscal year. In FY 2014 and each subsequent fiscal year, each hospital described in section 1886(d)(1)(B)(v) of the Act shall submit data to the Secretary on quality measures (QMs) specified under section 1866(k)(3) of the Act in a form and manner, and at a time, specified by the Secretary.

    The program requires PCHs to submit data for selected QMs to CMS. PCHQR is a voluntary quality reporting program, in which data will be publicly reported on a CMS website. In the FY 2012 IPPS rule, five NQF endorsed measures were adopted and finalized for the FY 2014 reporting period, which was the first year of the PCHQR program. In the FY 2013 IPPS rule, one additional measure was adopted. Twelve new measures were adopted in the FY 2014 IPPS rule and one measure was adopted in the FY 2015 IPPS rule. Data collection for the FY 2016 and FY 2017 reporting periods is underway. We published the FY 2014 measure rates on HospitalCompare.gov on October 1, 2014 after a 30-day preview period.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Communication and Care Coordination
      1. Measures regarding care coordination with other facilities and outpatient settings, such as hospice care.
      2. Measures of the patient’s functional status, quality of life, and end of life.
    2. Making Care Affordable
      1. Measures related to efficiency, appropriateness, and utilization (over/under-utilization) of cancer treatment modalities such as chemotherapy, radiation therapy, and imaging treatments.
    3. Person and Family Engagement
      1. Measures related to patient-centered care planning, shared decision-making, and quality of life outcomes.

    Measure Requirements: The following requirements will be considered by CMS when selecting measures for program implementation:

    1. Measure is responsive to specific program goals and statutory requirements.
      1. Measures are required to reflect consensus among stakeholders, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure specifications must be publicly available.
    3. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.
    4. Promote alignment with specific program attributes and across CMS and HHS programs. Measure alignment should support the measurement across the patient’s episode of care, demonstrated by assessment of the person’s trajectory across providers and settings.
    5. Potential use of the measure in a program does not result in negative unintended consequences (e.g., inappropriate reduced lengths of stay, overuse or inappropriate use of care or treatment, limiting access to care).
    6. Measures must be fully developed and tested, preferably in the PCH environment.
    7. Measures must be feasible to implement across PCHs, e.g., calculation, and reporting.
    8. Measure addresses an important condition/topic with a performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs.
    9. CMS has the resources to operationalize and maintain the measure.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Medicare Shared Savings Program 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: Section 3022 of the Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a Shared Savings Program that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery. The Medicare Shared Savings Program (Shared Savings Program) was designed to 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. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). If ACOs meet program requirements and the ACO quality performance standard, they are eligible to share in savings, if earned. There are two shared savings options: 1) one-sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year) and 2) two-sided risk model (sharing of savings and losses for all three years).

    Current Program Measure Information: The Affordable Care Act specifies appropriate measures of clinical processes and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization (such as rates of hospital admission for ambulatory sensitive conditions) and that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

    The Shared Savings Program quality reporting requirements are aligned with PQRS. Quality measure data for the Shared Savings Program is collected via claims and administrative data, CG-CAHPS, and the PQRS GPRO web interface.

    Measure Requirements: Specific measure requirements include:

    1. Outcome measures that address conditions that are high-cost and affect a high volume of Medicare patients.
    2. Measures that are targeted to the needs and gaps in care of Medicare fee-for-service patients and their caregivers.
    3. Measures that align with CMS quality reporting initiatives, such as PQRS and the VM.
    4. Measures that support improved individual and population health.

    Current Measures: NQF staff have compiled the 2016 MSSP measures in a spreadsheet organized according to concepts.

    Merit-Based Incentive Payment System (MIPS) 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: The Merit-Based Incentive Payment System (MIPS) is established by H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which repeals the Medicare sustainable growth rate (SGR) and improves Medicare payment for physician services. The MACRA consolidates the current programs of the Physician Quality Reporting System (PQRS), The Value-Based Modifier (VM), and the Electronic Health Records (EHR) Incentive Program into one program (MIPS) that streamlines and improves on the three distinct incentive programs. MIPS will apply to doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists beginning in 2019. Other professionals paid under the physician fee schedule may be included in the MIPS beginning in 2021, provided there are viable performance metrics available. Positive and negative adjustments will be applied to items and services furnished beginning January 1, 2019 based on providers meeting a performance threshold four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. Adjustments will be capped at 4 percent in 2019; 5 percent in 2020; 7 percent in 2021; and 9 percent in 2022 and future years.

    High Priority Domains for Future Measure Consideration: In the CY 2016 PFS Rule, CMS will not propose the implementation of measures that do not meet the MIPS criteria of performance and measure set gaps. MIPS has a priority focus on outcome measures and
    15
    measures that are relevant for specialty providers. CMS identifies the following domains as high-priority for future measure consideration:

    1. Person and caregiver-centered Experience and Outcomes
      1. CMS wants to specifically focus on patient reported outcome measures (PROMs)
    2. Communication and Care Coordination
      1. Measures addressing coordination of care and treatment with other providers
    3. Appropriate Use and Resource Use

    Measure Requirements: CMS applies criteria for measures that may be considered for potential inclusion in the MIPS. At a minimum, the following criteria and requirements must be met for selection in the MIPS:
    CMS is statutorily required to select measures that reflect consensus among affected parties, and to the extent feasible, include measures set forth by one or more national consensus building entities.
    To the extent practicable, quality measures selected for inclusion on the final list will address at least one of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention.

    Current Measures: NQF staff have compiled the 2016 MIPS measures in a spreadsheet organized according to concepts.

    Physician Compare 
    The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

    Program History and Structure: Section 10331 of the 2010 Patient Protection & Affordable Care Act (ACA) requires CMS to establish the Physician Compare website to publicly report physician performance data. The goal of the Physician Compare website is to provide reliable information for consumers to encourage informed health care decisions; and to create explicit incentives for physicians to maximize performance. To meet the statutory mandate, CMS repurposed the Medicare.gov Healthcare Provider Directory into Physician Compare. On December 30, 2010, CMS officially launched the Physician Compare website using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) as its underlying data source. Based on stakeholder feedback and understanding the Affordable Care Act (ACA) requirements for the site, CMS redesigned Physician Compare in June 2013. Since that time, CMS has been working continually to enhance the site and its functionality, improve the information available, and include more and increasingly useful information about the physicians and other health care professionals who are on the website.

    The 2012 Physician Fee Schedule final rule indicated that the first measures available for public reporting on Physician Compare would be a sub-set of the 2012 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) measures collected via the Web Interface. CMS publicly reported this first set of measure data in February 2014 for the 66 group practices and 141 ACOs. In December 2014, the next phase of public reporting was accomplished with the posting of a sub-set of the 2013 PQRS GPRO Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) measures collected via the Web Interface for 139 group practices and 214 Shared Savings Program and 23 Pioneer ACOS. In addition, CAHPS for ACO summary survey measures were added to Physician Compare. The following quality measures were publicly reported in December 2014:

    2013 PQRS GPRO and ACO measures


    2013 CAHPS for ACOs measures

    For 2014 data, all PQRS GPRO measures collected via the Web Interface, as well as a sub-set of measures reported via registry and EHR are available for public reporting on Physician Compare. All measures reported by Shared Savings Program and Pioneer ACOs are also available for public reporting. CMS will continue to publicly report 2014 CAHPS for ACOs and will publish the first set of CAHPS for PQRS measures for groups of 100 or more EPs who participate in PQRS GPRO and for group practices of 25-99 EPs reporting via a certified CAHPS vendor. In addition, twenty individual measures reported by EPs under the 2014 PQRS via claims, EHR, or registry are available for public reporting. All 2014 data are targeted for publication in late 2015.

    For 2015 data, at the group practice level, all 2015 PQRS GPRO measures reported via the Web Interface, registry, or EHR are available for public reporting. In addition, the 12 summary survey 2015 CAHPS for PQRS and CAHPS for ACO measures are available for public reporting for group practices of 2 or more EPs and ACOs reporting via a CMS-approved certified survey vendor. At the individual EP level, all 2015 PQRS measures reported via registry, EHR, or claims are available for public reporting. In addition, individual EP-level 2015 Qualified Clinical Data Registry (QCDR) measures, which include PQRS and non-PQRS data, will be available for public reporting on Physician Compare in late 2016.

    Current Program Measure Information: Table 1 below provides the number of quality measures under each domain of measurement from the National Quality Strategy (NQS) priorities that were finalized in the 2012, 2013, 2014 and 2015 PFS final rules as available for public reporting. Only those measures that are comparable, valid, reliable, and suitable for public reporting will be publicly reported on Physician Compare (see “Measure Requirements” below).

    Table 1: Quality Measures Finalized for Public Reporting by the 2012, 2013, 2014, & 2015 PFS Final Rules

    NQS Priority Domains
    		 Number of Measures Finalized for Potential Reporting on Physician Compare
    2012 PFS Final Rule
    		 2013 PFS Final Rule
    		 2014 PFS Final Rule
    		 2015 PFS Final Rule
    Groups
    		 ACOs
    		 Groups
    		 ACOs
    		 EPs
    		 Groups
    		 ACOs
    		 EPs
    		 Groups
    		 ACOs
    Effective Clinical Care
    		 27
    		 20
    		 20
    		 20
    		 13
    		 14
    		 14
    		 110
    		 138
    		 8
    Patient Safety
    		 1
    		 1
    		 1
    		 1
    		 2
    		 2
    		 2
    		 26
    		 34
    		 2
    Communication/Care Coordination
    		 1
    		 1
    		 1
    		 1
    		 0
    		 0
    		29
    		 37
    		 0
    Community/Population Health
    		 0
    		 0
    		 0
    		 0
    		 5
    		 5
    		 5
    		 14
    		 15
    		 5
    Efficiency and Cost Reduction
    		 0
    		 0
    		 0
    		 0
    		 0
    		 0
    		 0
    		 15
    		 16
    		 0
    Person and Caregiver Centered Experience and Outcomes
    		 0
    		 0
    		 25
    		 35
    		 0
    		 12
    		 12
    		 12
    		 14
    		 12

    High Priority Domains for Future Measure Consideration: As we move more toward expanded public reporting, it is critical to include consumer-friendly measures. This means that measure development needs to focus on creating measures that look at the types of information consumers need to know to make informed health care decisions. PQRS was originally a pay-for-reporting program without explicit intent to publicly report quality measures. However, starting with 2015 data, all PQRS measures are available for public reporting on Physician Compare. Based on this expansion of public reporting and the changing use of PQRS measures, it is critical to consider public reporting and the consumer perspective during measure development. CMS identified the key areas to consider when developing consumer-friendly measures.

    Consumer testing has also shown that users prefer outcome measures over process measures. In order for quality measures to be meaningful to consumers, they must resonate with consumers. We often hear that consumers do not think process measures are useful. They want to understand if patients like them better or if a procedure was successful. This is the information that will help them make informed decisions.

    Composite measures can help consumers accurately interpret measures in a way that is meaningful to them while also removing the burden of interpretation from them. Composite measures help make data more digestible. It is much easier for a consumer to understand that a doctor is good at diabetes care, for instance, than it is to understand why it is important for a doctor to perform well across a series of technical measures about glucose levels and treatment best practices. Similarly, risk adjustment can ensure that consumers are more accurately comparing health care professionals and group practices.

    Consumers can provide valuable feedback when engaged early in the measure development process. They can determine if measures are understandable and useful in decision making. We understand that all measures are not intended for public reporting. However, the continued growth of public reporting makes the consumer perspective increasingly important. Moving towards more consumer-friendly measures, specifically outcome measures, composite measures, and risk-adjusted measures, will be instrumental toward achieving Physician Compare’s goal, as defined by the Affordable Care Act, of providing consumers useful quality data to inform health care decisions.

    Measure Requirements: Although CMS has finalized the quality measures listed in Table 1 for public reporting, not all of these quality measures may ultimately be suitable for public reporting. Only comparable, valid, reliable, and accurate data will be publicly reported. For example, the performance results for certain measures may not be statistically reliable if the total number of patients reported on is low. Hence, to select a sub-set of quality measures finalized for public reporting, CMS will need to analyze the actual measure performance results collected for each program year. At minimum, any quality measures selected for public reporting must meet the following criteria:

    In addition, CMS will not publish any measures that are in their first year and only those measures that prove to resonate with consumers and are deemed to be relevant to consumers will be included on the profile pages of the website. All other comparable, valid, reliable, and accurate measures would be included in a publicly available downloadable database, similar to the databases currently available on data.medicare.gov.

    Current Measures: The measures for Physician Compare are drawn from PQRS/MIPS, and NQF staff compiled the 2016 MIPS measures in a spreadsheet.

    Appendix C: Public Comments

    Index of Measures (by Program)

    All measures are included in the index, even if there were not any public comments about that measure for that program.

    General Comments

    Ambulatory Surgical Center Quality Reporting Program

    End-Stage Renal Disease Quality Incentive Program

    Hospital Acquired Condition Reduction Program

    Home Health Quality Reporting Program

    Hospital Inpatient Quality Reporting and EHR Incentive Program

    Hospital Outpatient Quality Reporting Program

    Hospice Quality Reporting Program

    Hospital Value-Based Purchasing Program

    Inpatient Psychiatric Facility Quality Reporting Program

    Inpatient Rehabilitation Facility Quality Reporting Program

    Long-Term Care Hospital Quality Reporting Program

    Merit-Based Incentive Payment System (MIPS)

    Medicare Shared Savings Program

    Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program

    Skilled Nursing Facility Quality Reporting System

    Skilled Nursing Facility Value-Based Purchasing Program

    Full Comments (Listed by Measure)

    General comments on the Clinician workgroup recommendations/ draft report
    General
    General comments on the Hospital workgroup recommendations/draft report
    General comments on the PAC/LTC workgroup recommendations/ draft report
    Adult Local Current Smoking Prevalence (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1013)
    INR Monitoring for Individuals on Warfarin after Hospital Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1015)
    Non-Recommended PSA-Based Screening (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1019)
    Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1033)
    Toxic Anterior Segment Syndrome (TASS) Outcome (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC15-1047)
    Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) (required by PAMA) (Program: Skilled Nursing Facility Value-Based Purchasing Program; MUC ID: MUC15-1048)
    Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1065)
    Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1082)
    IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1083)
    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-1127)
    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-1128)
    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-1129)
    Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1130)
    Percent of Skilled Nursing Facility Residents Who Self-Report Moderate to Severe Pain (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1131)
    Percent of Skilled Nursing Facility Residents Who Were Assessed and Appropriately Given the Influenza Vaccine (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1132)
    Percent of Skilled Nursing Facility Residents Who Newly Received an Antipsychotic Medication (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-1133)
    Medicare Spending Per Beneficiary-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-1134)
    Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1135)
    Measurement of Phosphorus Concentration (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1136)
    Cellulitis Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1143)
    Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1144)
    Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1145)
    Proportion of Patients with Hypercalcemia (NQF #1454) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1165)
    Standardized Readmission Ratio (SRR) for dialysis facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1167)
    Potential Opioid Overuse (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1169)
    Use Of Preventive Screening Protocol For Transplant Patients (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-177)
    Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-178)
    Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-179)
    Falls risk composite process measure (Program: Home Health Quality Reporting Program; MUC ID: MUC15-207)
    Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-208)
    Non-selective beta blocker use in patients with esophageal varices (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-209)
    Hepatitis A vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-210)
    Hepatitis B vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-211)
    Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-212)
    Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-215)
    NMSC: Biopsy Reporting Time - Pathologist (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-216)
    Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-217)
    Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-220)
    Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-221)
    Hospice Visits When Death Is Imminent (Program: Hospice Quality Reporting Program; MUC ID: MUC15-227)
    Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-229)
    HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-230)
    Hospice and Palliative Care Composite Process Measure (Program: Hospice Quality Reporting Program; MUC ID: MUC15-231)
    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-234)
    Improvement in Dyspnea in Patients with a Primary Diagnosis of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and/or Asthma (Program: Home Health Quality Reporting Program; MUC ID: MUC15-235)
    Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-236)
    Screening endoscopy for varices in patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-251)
    Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-275)
    Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Medicare Shared Savings Program; MUC ID: MUC15-275)
    Medicare Spending per Beneficiary-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-287)
    Medicare Spending per Beneficiary-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-289)
    Medicare Spending per Beneficiary-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-291)
    Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-294)
    Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-295)
    New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-296)
    Performance of objective measure of functional hearing status (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-307)
    Patient-Reported Functional Communication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-313)
    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-322)
    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-369)
    Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-370)
    Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-372)
    Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-374)
    Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-375)
    Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-377)
    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-378)
    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-378)
    Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-379)
    Excess Days in Acute Care after Hospitalization for Pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-391)
    Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-392)
    Diabetic Macular Edema: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-393)
    Acute Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-394)
    Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-395)
    Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-396)
    Chronic Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-397)
    Ventilator Weaning (Liberation) Rate (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-398)
    Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-399)
    Compliance with Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar Trial (TCT) or Continuous Positive Airway Pressure (CPAP) Breathing Trial)) by Day 2 of the LTCH Stay (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-400)
    30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-402)
    Discharge to Community-Post Acute Care (PAC) Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-408)
    Patient reported outcomes following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-411)
    Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-412)
    Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-413)
    Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-414)
    Proportion admitted to hospice for less than 3 days (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-415)
    Rate of adequate percutaneous image-guided biopsy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-420)
    Efficacy of uterine artery embolization for symptomatic uterine fibroids (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-423)
    Common femoral arterial access site complication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-424)
    Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-434)
    Over-utilization of mesh in the posterior compartment (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-436)
    Route of hysterectomy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-437)
    Testing for uterine disease prior to obliterative procedures (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-439)
    Documentation of offering a trial of conservative management prior to fecal incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-440)
    Documentation of offering a trial of conservative management prior to urgency incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-441)
    Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-450)
    Minimally invasive surgery performed for patients with endometrial cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-452)
    Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-454)
    Surgical staging with lymph node removal for any grade 3 and/or myometrial invasion >50% with endometrial cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-459)
    Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-460)
    Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-461)
    Discharge to Community-Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-462)
    Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-463)
    Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-465)
    Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-466)
    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-495)
    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation Facility Quality Reporting Program (Required under the IMPACT Act) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-496)
    Potentially Preventable Within Stay Readmission Measure for Inpatient Rehabilitation Facilities (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC15-497)
    Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital Quality Reporting Program (Required under the IMPACT Act) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-498)
    Discharge to Community-Post Acute Care (PAC) Home Health Quality Reporting Program (Required under the IMPACT Act) (Program: Home Health Quality Reporting Program; MUC ID: MUC15-523)
    Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-527)
    Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-528)
    Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) (Program: Skilled Nursing Facility Quality Reporting System; MUC ID: MUC15-529)
    Percent of Patients Who Received an Antipsychotic (AP) Medication (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC15-530)
    National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-531)
    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-532)
    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-533)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-534)
    Standardized Mortality Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-575)
    Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-576)
    Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-576)
    PQI 91 Prevention Quality Acute Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-577)
    PQI 91 Prevention Quality Acute Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-577)
    Advance Care Plan (Program: Medicare Shared Savings Program; MUC ID: MUC15-578)
    Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (Program: Medicare Shared Savings Program; MUC ID: MUC15-579)
    Patient Safety and Adverse Events Composite (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-604)
    Patient Safety and Adverse Events Composite (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-604)
    Patient Safety and Adverse Events Composite (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-604)
    Standardized Hospitalization Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-693)
    Avoidance of Utilization of High Ultrafiltration Rate (= 13 ml/kg/hour) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-758)
    ESRD Vaccination: Full-Season Influenza Vaccination (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-761)
    Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-835)
    Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-836)
    Spinal Fusion Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-837)
    Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-838)
    Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-928)
    Oncology: Radiation Dose Limits to Normal Tissues (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-946)
    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-951)
    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-951)
    Risk-standardized hospital visits within 7 days after hospital outpatient surgery (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-982)

    Appendix D: Instructions and Help

    If you have any problems navigating the discussion guide, please contact us at: MAPcoordinatingcommittee@qualityforum.org

    Navigating the Discussion Guide

    Content

    Appendix E: Instructions for Joining the Meeting Remotely

    Remote Participation Instructions:

    Streaming Audio Online Teleconference