Agenda | Measures | Programs | Comments

NQF

Version Number: 2.5
Meeting Date: December 9-10, 2015

Measure Applications Partnership
Clinician Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Day 1-December 9, 2015
8:30 am	Breakfast
9:00 am	Welcome, Disclosures of Interest, Review Meeting Objectives
9:20 am	Pre-Rulemaking Opening Remarks
9:40am	Overview of Pre-Rulemaking Approach
10:00 am	Overview of the Medicare Shared Savings Program (MSSP)
10:30 am	Break
10:45 pm	Opportunity for Public Comment on Medicare Shared Savings Program Consent Calendar
11:00 am	Consent Calendar: Medicare Shared Savings Program
12:00 pm	Lunch
12:30 pm	Overview of the Merit-Based Incentive Payment System (MIPS) and Physician Compare Programs
1:15 pm	Opportunity for Public Comment on Dermatology Consent Calendar
1:30 pm	Consent Calendar- Dermatology
2:15 pm	Break
2:30 pm	Opportunity for Public Comment on Eye Care Consent Calendar
2:45 pm	Consent Calendar- Eye Care
3:45 pm	Opportunity for Public Comment on Cancer Consent Calendar
4:00 pm	Consent Calendar- Cancer
4:45 pm	Opportunity for Public Comment
5:00 pm	Adjourn
Day 2-December 10, 2015
8:00 am	Breakfast
8:30 am	Welcome and Recap of Day 1
8:45 am	Opportunity for Public Comment on Interventional Radiology Consent Calendar
9:00 am	Consent Calendar- Interventional Radiology
10:00 am	Break
10:15 pm	Opportunity for Public Comment on Urogynecology Consent Calendar
10:30 pm	Consent Calendar- Urogynecology
11:30 pm	Opportunity for Public Comment on Gastroenterology Consent Calendar
11:45 pm	Consent Calendar- Gastroenterology
12:30 pm	Lunch
1:45 pm	Opportunity for Public Comment on Miscellaneous Consent Calendar
1:00 pm	Consent Calendar-Miscellaneous
2:00 pm	Workgroup Discussion – Gaps in the Clinician program measure sets
2:30 pm	Workgroup Discussion – Alignment
3:00 pm	Workgroup discussion – Public reporting of clinician measures
3:30 pm	Opportunity for Public Comment
3:45 pm	Summary of the MAP Clinician Workgroup pre-rulemaking input
4:00 pm	Adjourn

Full Agenda

Day 1-December 9, 2015

8:30 am	Breakfast

9:00 am	Welcome, Disclosures of Interest, Review Meeting Objectives
	Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair; Chris Cassel, CEO, NQF; Reva Winkler, Senior Director, NQF; Ann Hammersmith, General Counsel, NQF
9:20 am	Pre-Rulemaking Opening Remarks
	Kate Goodrich, CMS
9:40am	Overview of Pre-Rulemaking Approach
	Andrew Lyzenga, Senior Project Manager, NQF; Poonam Bal, Project Manager, NQF
10:00 am	Overview of the Medicare Shared Savings Program (MSSP)
	Rabia Khan, CMS (MSSP); Dr. Winkler
10:30 am	Break

10:45 pm	Opportunity for Public Comment on Medicare Shared Savings Program Consent Calendar

11:00 am	Consent Calendar: Medicare Shared Savings Program
	Provide recommendations on measures under consideration; Identify high-priority measure gaps for the program
	Reactors: Marci Nielsen ; Kate Koplan
	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: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention of falls is a cross-cutting, patient safety measure applicable to all Medicare patients. This NQF-endorsed measure is aligned with PQRS. Impact on quality of care for patients:According to the CDC, one out of three adults aged 65 or older falls each year, but less than half talk to their healthcare providers about it, suggesting an opportunity for improvement that would be addressed by this measure. The CDC reports that falls are the leading cause of both fatal and nonfatal injuries in older adults, and that in 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion. Preliminary analysis result: Support Advance Care Plan (MUC ID: MUC15-578) Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (Measure Specifications; Summary of NQF Endorsement Review) Programs under consideration: Medicare Shared Savings Program Public comments received: 5 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is aligned with PQRS/MIPS, addresses an important need for patients and caregivers and is a cross-cutting communication and care coordination measure applicable to all Medicare patients.. Impact on quality of care for patients:In 2010, there were 40.3 million people aged 65 and older, a 13% share of the US population, that is projected to reach 20.9% by 2050. As people age, consideration should be given to their treatment wishes in the event that they lose the ability to manage their care. A large discrepancy exists between the wishes of dying patients and their actual end-of-life care. Advance Care Plan is recommended as a strategy to improve compliance with patient wishes, and thereby ensure appropriate use of health care resources at the end of life. Preliminary analysis result: Support 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: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. A risk-model that includes co-morbidities is being devloped. Impact on quality of care for patients:This measure encourages appropriate care of acute conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families. Preliminary analysis result: Encourage continued development 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: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the ACO level of analysis and submitted to NQF. Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs. Preliminary analysis result: Encourage continued development 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: Medicare Shared Savings Program Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) – both are all-or-none composite measures for ischemic vascular disease . CMS recently removed PQRS #349 because it is duplicative of the Millions Hearts measures. The approach for cardiovascular measures should be aligned in both PQRS/MIPS and MSSP. Impact on quality of care for patients: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 – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance. Preliminary analysis result: Do not support
12:00 pm	Lunch

12:30 pm	Overview of the Merit-Based Incentive Payment System (MIPS) and Physician Compare Programs
	Molly A. MacHarris, CMS (MIPS); Alesia D. Hovatter, CMS (Physician Compare); Dr. Winkler
1:15 pm	Opportunity for Public Comment on Dermatology Consent Calendar

1:30 pm	Consent Calendar- Dermatology

	Reactors: Scott Furney (MIPS); Stephen Friedhoff (MIPS); Bruce W. Sherman (Physician Compare)
	Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (MUC ID: MUC15-215) Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure adds a communication measure. Data on current performance would provide a better understanding of the gap in care. . This patient centered-communication measure should be expanded to include all biopsies performed by any clinician for any condition. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Impact on quality of care for patients:Patients should expect a timely report on the results of any biopsy. There are more new cases of skin cancer reported each year than cancers of the breast, prostate, lung and colon combined (http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf).The most common types of skin cancer are basal cell and squamous cell skin cancer, most commonly referred to as non-melanoma skin cancer or NMSC. The most recent study from 2006 estimated 3.5 million cases of NMSC were diagnosed from 2.2 million people. Currently, pathology reports are received by the biopsying clinician within 10 days after the biopsy is performed (cancer.org) and even longer for the clinician to share the results with the patient. Effective and timely communication between the clinician and patient is essential to ensuring safe and effective patient care along with reducing cost. Preliminary analysis result: Encourage continued development Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (MUC ID: MUC15-215) Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an important communications measure Preliminary analysis result: Clinician web page 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: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:A measure that evaluates the reporting time between pathologist and biopsying clinician should not be restricted to dermatology biopsies. Strong consideration should be given to expanding this communication measure to all biopsies. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Data on current performance is needed to understand the gap in care. Impact on quality of care for patients:Timely pathology reports are essential to inform the patient and plan treatment. Patients should expect a timely report on the results of any biopsy. Delays or lost reports are potentially quite costly. Effective and timely communication between the two practitioners is essential to ensuring timely and effective patient care. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (MUC ID: MUC15-178) Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an appropriate use measure for dermatology. 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 cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique. Preliminary analysis result: Encourage continued development Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (MUC ID: MUC15-178) Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Performing Mohs surgery is often advertised by clinicians to encourage consultation with their practice. Preliminary analysis result: Clinician web page 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 (MUC ID: MUC15-179) Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is another appropriate use measure for dermatology. 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 cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique. Preliminary analysis result: Encourage continued development 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 (MUC ID: MUC15-179) Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Doing Mohs surgery is often advertised by clinicians to encourage consultation with their practice. Preliminary analysis result: Clinician web page Use Of Preventive Screening Protocol For Transplant Patients (MUC ID: MUC15-177) Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is a process measure assessing whether screening and education activities have been performed. This measure addresses population health and prevention. The measure adds to the measures specific to dermatology, and addresses the new area of organ transplant recipients. No data is provided to understand current performance or gap in care. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Impact on quality of care for patients:29,532 people received organ transplants in 2014. Due to the effects of immunosuppressive medications and other risk factors, these recipients are at significantly higher risk for skin cancer. If patients are already receiving screening and education, the impact on patients will be limited. Preliminary analysis result: Encourage continued development Use Of Preventive Screening Protocol For Transplant Patients (MUC ID: MUC15-177) Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page
2:15 pm	Break

2:30 pm	Opportunity for Public Comment on Eye Care Consent Calendar

2:45 pm	Consent Calendar- Eye Care

	Reactors: Scott Friedman (MIPS); Beth Averbeck (MIPS); Robert Krughoff (Physician Compare)
	Glaucoma - Intraocular Pressure (IOP) Reduction (MUC ID: MUC15-372) Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This intermediate outcome measure is very similar to PQRS # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care. This new MUC might be an improvement on PQRS #141.This MUC differentiates the outcome threshold based on severity of disease and does not have the plan of care component. No information regarding the targets specified in this measure could be identified nor evidence that these targets are related to specific outcomes. Impact on quality of care for patients:There are approximately 4 million Americans with glaucoma – 200,000 are severely visually impaired. Reduction of intraocular pressure (IOP) has been shown to effectively reduce the risk of glaucoma progression. American Association of Ophthalmology guidelines recommend “The goal of glaucoma treatment is to maintain the IOP in a range at which a patient is likely to remain stable or at which worsening of glaucoma will be slow enough that the risk of additional intervention is not justified. The target pressure should be individualized and may need adjustment during the course of the disease.” Evidence level A:III. Preliminary analysis result: Encourage continued development Glaucoma - Intraocular Pressure (IOP) Reduction (MUC ID: MUC15-372) Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (MUC ID: MUC15-374) Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an additional outcome measure for patients undergoing laser surgery for glaucoma. Clarification of the timing of the post-operative pressure measurement is needed. Impact on quality of care for patients:Surgery is used when medications fail to control vision loss caused by glaucoma. Laser surgery is done more often than conventional surgery. The most common complication from laser surgery for glaucoma is increased pressure within the eye that may rise sharply 1-4 months after surgery. The measure does not specify a timeframe for measuring the IOP after surgery– if performed too soon the measure may not capture increased pressures that occur several months after surgery and would over estimate good outcomes. Preliminary analysis result: Encourage continued development Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (MUC ID: MUC15-374) Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-379) Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an outcome measures for a topic with only process measures currently. Since AMD is a slowly progressive condition, it is unclear whether this outcome measure is a function of the natural progression of the disease and to what extent clinical management will influence the outcome. Impact on quality of care for patients:There is an estimated 1.75 million cases of advanced AMD in the US. AMD is the leading cause of irreversible visual loss in the United States, with variable degrees of age-related macular changes occurring in more than 10% of the population aged 65-74 years and 25% of the population older than 74 years. Therapy with anti-VEGF agents is the gold standard with promising results, many intravitreal injections are often required, and they do not cure all cases of wet (neovascular) AMD. A Mayo Clinic study reported that “the anti-VEGF therapy yielded improved best-corrected visual acuity. “ Preliminary analysis result: Encourage continued development Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-379) Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-392) Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This MUC is an outcome measure for a condition that only has process measures. It is unclear whether the degree of vision change quantified in this measure will reflect the natural slow progression of the disease or the impact of optimal treatment to slow down disease progression. Impact on quality of care for patients:Non-exudative AMD comprises more than 90% of patients with AMD and generally has a much slower (over decades), progressive visual loss relative to exudative (wet) AMD). There is currently no cure for AMD, but treatments may prevent severe vision loss or slow the progression of the disease considerably. Not all patients with AMD are candidates for use of the AREDS vitamin formulation. Taking the AREDS vitamins was shown to reduce the risk of advanced AMD by 25%. Preliminary analysis result: Encourage continued development Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-392) Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Diabetic Macular Edema: Loss of Visual Acuity (MUC ID: MUC15-393) Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an outcome measure for a large population at risk of vision loss. Vision loss associated in patients with diabetes can be reduced with good diabetes care. Care coordination among primary and eye care providers is essential to maintain vision. Impact on quality of care for patients:Macular edema in common in diabetes. The lifetime risk for diabetics to develop macular edema is about 10%. The condition is closely associated with the degree of diabetic retinopathy (retinal disease). The standard of treatment for diabetic macular edema is glycemic control, optimal blood pressure control, and macular focal/grid laser photocoagulation. New treatments with steroids and anti-VEGF agents are available. Optimal treatment can reduce the risk of vision loss and associated functional limitations in patients with diabetes. Preliminary analysis result: Encourage continued development Diabetic Macular Edema: Loss of Visual Acuity (MUC ID: MUC15-393) Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (MUC ID: MUC15-370) Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:A functional outcome measure for eye care professionals. Data on current performance would provide better understanding on the opportunity for improvement. Impact on quality of care for patients:More than 40,000 corneal transplants or grafts are performed each year in the US. Good vision after any eye procedure is the goal for patients and providers. Preliminary analysis result: Encourage continued development Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (MUC ID: MUC15-370) Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (MUC ID: MUC15-375) Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 5 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an outcome measure for oculoplastic surgeons – a subspecialty with few or no measures. Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes. As many surgeries are performed primarily for cosmetic reasons a patient-reported outcome measure is also needed. Impact on quality of care for patients:Ptosis is a lowering of the eyelid to below its normal position. The distance between the corneal light reflex and the upper eyelid margin is termed the upper marginal reflex distance. The official definition of ptosis is an upper marginal reflex distance below 2 mm or an asymmetry of more than 2 mm between the eyes. Ptosis has many causes and is a presenting symptom in both emergency and outpatient settings. In many cases, ptosis improves with time, however, in the absence of improvement surgery may be considered. Data on current performance to determine the opportunity for improvement could not be identified. Preliminary analysis result: Encourage continued development Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (MUC ID: MUC15-375) Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Acquired Involutional Entropion: Normalized lid position after surgical repair (MUC ID: MUC15-377) Description: Percentage of surgical entropion patients with a postoperative normalized lid position (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 5 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure adds a surgical outcome measure for ophthalmologists, however, It is unclear what the current performance is. As this procedure is sometimes done for cosmetic reasons, a patient-reported outcome would be important also. Impact on quality of care for patients:Entropion is an inversion of the eyelid (i.e., inward turning of the eyelid margin) toward the globe. Lower lid entropion is a common condition in elderly individuals; the prevalence increases steadily with age. Involutional entropion is the most common form of entropion. Patients seek treatment due to eye irritation, watering of the eye or cosmetic concerns. Involutional entropion has a prevalence of 2.4% in whites and 0.8% in blacks. No data on current performance could be identified. Preliminary analysis result: Encourage continued development Acquired Involutional Entropion: Normalized lid position after surgical repair (MUC ID: MUC15-377) Description: Percentage of surgical entropion patients with a postoperative normalized lid position (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Acute Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-394) Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an outcome measure evaluating the effectiveness of treatment for an eye condition not yet represented in the clinician measure set. Impact on quality of care for patients:Anterior uveitis is an inflammation of the middle layer of the eye, which includes the iris (colored part of the eye) and adjacent tissue. If untreated, it can cause permanent damage and loss of vision from the development of glaucoma, cataract or retinal edema. It usually responds well to treatment with eye drops. The annual incidence rate is approximately 8 cases per 100,000 population, most commonly in the fourth and fifth decades of life. Preliminary analysis result: Encourage continued development Acute Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-394) Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-396) Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Acute Anterior Uveitis: Post-treatment visual acuity. Impact on quality of care for patients:The presence of Grade 0 anterior chamber cells indicates reduced inflammation in response to therapy. Though signs of improvement are welcome, the important outcomes are reduction in patient symptoms and good vision. Preliminary analysis result: Encourage continued development Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-396) Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Chronic Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-397) Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an outcome measure for patients with a chronic condition. It is not clear whether patients that fail treatment for acute uveitis in MUCFIFTEEN-394 Acute Anterior Uveitis: Post-treatment visual acuity are the patients in this measure or when the 90 days specified begins. Impact on quality of care for patients:Chronic uveitis is active uveitis that persists longer than three months. Chronic anterior uveitis is insidious in onset, persistent, associated with a high incidence of visually threatening complications, and has a variable long term visual prognosis. It may be associated with systemic diseases such as juvenile chronic arthritis, Behçet's disease, and sarcoidosis. The aims of treatment are to control inflammation, prevent visual loss, and minimize long term complications of the disease and its treatment. Maintaining vision is critically important in treating this condition. Preliminary analysis result: Encourage continued development Chronic Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-397) Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-399) Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Chronic Anterior Uveitis: Post-treatment visual acuity. Preliminary analysis result: Encourage continued development Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-399) Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet
3:45 pm	Opportunity for Public Comment on Cancer Consent Calendar

4:00 pm	Consent Calendar- Cancer

	Reactors: Janis Orlowski (MIPS); Constance Dahlin (MIPS); Amy Moyer (Physician Compare)
	Non-Recommended PSA-Based Screening (MUC ID: MUC15-1019) Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 42 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure fills a need for appropriate use/overuse measures that apply to a broad population of patients. Impact on quality of care for patients: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. Unnecessary screening tests are costly and create unnecessary anxiety and follow up evaluations for patients. Preliminary analysis result: Encourage continued development Non-Recommended PSA-Based Screening (MUC ID: MUC15-1019) Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure provides patients and other stakeholders with information about clinicians that do not follow guidelines and contribute to unnecessary costs. Preliminary analysis result: Clinician web page Proportion admitted to hospice for less than 3 days (MUC ID: MUC15-415) Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there (Measure Specifications; Summary of NQF Endorsement Review) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure addresses an important gap area in end-of-life care for reporting by oncologists, is fully-specified and tested, reflects patient-centered care, and addresses the important areas of care coordination and appropriate use. MAP has previously recommended expanding this measure beyond cancer patients. Impact on quality of care for patients:Approximately 500,000 patients will die of cancer in 2015. A 2014 study (Obermeyer Z, Makar M, et al) found that in Medicare fee-for-service beneficiaries with poor-prognosis cancer, a comparison of those receiving hospice care (60%) vs not (control) showed that hospice patients had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life. Preliminary analysis result: Support Proportion admitted to hospice for less than 3 days (MUC ID: MUC15-415) Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there (Measure Specifications; Summary of NQF Endorsement Review) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Minimally invasive surgery performed for patients with endometrial cancer (MUC ID: MUC15-452) Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an surgical appropriateness measure for uterine cancer care for GYN and GYN ONC. There are no other measures for endometrial cancer – an important condition in the Medicare population. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:Studies show that minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) has no difference in survival compared to open surgery, but patients undergoing minimally invasive surgery had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks. Measure submitter reports that data indicates variation in performance of 50-90%. Improvement in this measure would improve the quality of care for patients with endometrial cancer and reduce costs. Preliminary analysis result: Encourage continued development Minimally invasive surgery performed for patients with endometrial cancer (MUC ID: MUC15-452) Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (MUC ID: MUC15-465) Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Data on current performance is needed to assess whether there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:Radical hysterectomy is the standard procedure for women who undergo surgical treatment for cervical cancer. This is a more extensive surgery aimed at curing the cancer. If most women are receiving this standard of care, there will be little improvement from use of this measure. Preliminary analysis result: Encourage continued development Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (MUC ID: MUC15-465) Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (MUC ID: MUC15-460) Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is a process measure closely linked to clinical outcomes (patient survival) with a demonstrated quality problem/opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:In the US there were 12,900 cases and 4100 deaths from cervical cancer this year. Radiation therapy is included in treatment protocols for all but the earliest stage of cancer. Brachytherapy is internal radiation placed in and near the cervix with minimal radiation exposure to other areas. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. According to the American Brachytherapy Society Cervical Cancer Brachytherapy Task Group “The radiation dose delivered by brachytherapy is critical in curing patients of cervical cancer and has been the standard of treatment for over 100 years.” 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. Improvement in use of brachytherapy will improve survival in women with cervical cancer. Preliminary analysis result: Encourage continued development Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (MUC ID: MUC15-460) Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (MUC ID: MUC15-461) Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is closely related to patient survival. Data on current performance would provide a better understanding of the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:Treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased treatment failure rates and decreased cancer specific and overall survival. If there is a gap in current performance, improved performance would improve patient survival. Preliminary analysis result: Encourage continued development Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (MUC ID: MUC15-461) Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet 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. (MUC ID: MUC15-466) Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy) (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:As combination therapy is the standard of care for patients with spread of cervical cancer beyond surgical margins, it is unclear whether there is an opportunity for improvement. Unless data can demonstrate there is a gap in care, this measure will add little to the current set. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:The National Cancer Institute recommends that platinum containing chemotherapy be added to post-operative radiation therapy for patients with tumor spread beyond the cervix. If patients are receiving this standard of care treatment, little additional gain is likely from use of this measure. Preliminary analysis result: Encourage continued development 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. (MUC ID: MUC15-466) Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy) (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (MUC ID: MUC15-463) Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure for treatment of advanced cervical cancer is one of four new measures for cervical cancer management – an area that does not have current measures. Data on current performance is needed to understand the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:A 2010 Cochrane review found that women who had chemoradiotherapy for cervical cancer were likely to live for longer than women who had just radiotherapy. Although this measure promotes the best recommended care and should improve the outcomes for women with cervical cancer, it is unclear how many patients are not receiving appropriate chemoradiation therapy. The impact will be limited if patients are already receiving this standard of care. Preliminary analysis result: Encourage continued development Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (MUC ID: MUC15-463) Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet 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 (MUC ID: MUC15-454) Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Currently there are few measures for ovarian cancer and GYN ONC specialists, however, there is no evidence that patients are not receiving this standard of care – the opportunity for improvement may be limited. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma according to analysis of patient data in the prospective OVCAD study. (Gynecologic oncology. 2013;131:15-20. PMID= 23877013). However, the impact is limited if there is no opportunity for improvement. Preliminary analysis result: Encourage continued development 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 (MUC ID: MUC15-454) Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-450) Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:There is no information that there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry. Impact on quality of care for patients:It is unclear how many patients are not receiving this standard of care. The impact of the measure is limited if current performance is very high. Preliminary analysis result: Encourage continued development Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-450) Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet
4:45 pm	Opportunity for Public Comment

5:00 pm	Adjourn

Day 2-December 10, 2015

8:00 am	Breakfast

8:30 am	Welcome and Recap of Day 1
	Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair
8:45 am	Opportunity for Public Comment on Interventional Radiology Consent Calendar

9:00 am	Consent Calendar- Interventional Radiology

	Reactors: Paul N. Casale (MIPS); David J. Seidenwurm (MIPS); Rachel Grob (Physician Compare)
	Rate of adequate percutaneous image-guided biopsy (MUC ID: MUC15-420) Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This intermediate outcome measure assesses imaging specialists for a wide variety of patient conditions. The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. A consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes. Impact on quality of care for patients:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies Preliminary analysis result: Encourage continued development Rate of adequate percutaneous image-guided biopsy (MUC ID: MUC15-420) Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies. Preliminary analysis result: Clinician web page Efficacy of uterine artery embolization for symptomatic uterine fibroids (MUC ID: MUC15-423) Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This patient-reported outcome measure provides the patient perspective on the outcome of this procedure for a common condition -- uterine fibroids. This measure is also valuable for public reporting to patients and consumers. It is unclear how the results of the UFS-QOL survey would be submitted to MIPS. It is also unclear whether the UFS-QOL survey is the only acceptable tool – the cost of the survey is $2500. Impact on quality of care for patients:Uterine artery embolization (UAE) is an alternative treatment for women with symptomatic fibroids of the uterus. Since the purpose of the procedure is to reduce symptoms, the patient is in the best position to know whether the treatment improved her symptoms or not. Aggregate data from the literature reports that 80-85% of women report improvement in their symptoms. UAE avoids the risks of major surgery (hysterectomy) though the costs are similar. 20% of patients require additional treatment after UAE. If UAE is promoted as a less invasive, safer treatment than traditional surgery, it is important to know that the results for patients are good. Preliminary analysis result: Encourage continued development Efficacy of uterine artery embolization for symptomatic uterine fibroids (MUC ID: MUC15-423) Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Common femoral arterial access site complication (MUC ID: MUC15-424) Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an adverse outcome measure for vascular access performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Impact on quality of care for patients:Arterial access is performed for a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Clinical guidelines have noted that “modest hematomas from femoral arterial access occur in up to 10% of patients, where as major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable.” Measurement of adverse outcomes provides meaningful information for patients. It is unclear whether the distinction between “modest hematoma” (which does not count in the measure) and “major hematoma” will result in reliable results without better definitions. Preliminary analysis result: Encourage continued development Common femoral arterial access site complication (MUC ID: MUC15-424) Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (MUC ID: MUC15-402) Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This adverse outcome measure is a “companion” measure to PQRS #345 - Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) and captures a different patient population – those with symptoms (but not acute emergencies.) This measure is intended for interventional radiologists and addresses the quality domain of patient safety. CONDITION: The measure should be submitted to NQF for endorsement. Impact on quality of care for patients:Minimizing complications from a procedure is important and comparing complication rates among providers is critical for patients and families when making decisions about healthcare. The American Heart Association and American Stroke Association recommend a complication rate less than 6% for carotid artery stenting. Complication rates higher than 6% negate the potential benefit of stroke risk reduction. The CREST trial, compared stenting to surgery found that there was no significant differences out to four years of follow-up between surgery and carotid stenting when counting all three, but carotid endarterectomy (CEA) has a higher risk of heart attacks and CAS has a higher risk of minor stroke than open surgery.[1] Overall, younger patients (<70 years old) had better outcomes with stenting than with surgery. Preliminary analysis result: Conditional support 30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (MUC ID: MUC15-402) Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Patient reported outcomes following ilio-femoral venous stenting (MUC ID: MUC15-411) Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This PRO adds important information for public reporting and quality of care that is meaningful to patients and their families. The measure is intended for interventional radiologists. No information is provided on cost of the survey and it is unclear how the survey results will be transmitted to MIPS. Impact on quality of care for patients:Ilio-femoral vein stenting has become a safe and effective alternative to traditional open surgery to correct iliac vein obstruction. A RAND evidence review in 2013 reported relief of pain (86-94%), relief from swelling (66%-89%) and healing of venous ulcers (55-89%) in published studies. The RAND summary concluded the benefits outweigh the risks (1B). This PRO can provide important information on performance for patients and other stakeholders seeking information on outcomes from the patient perspective and high-quality care. Preliminary analysis result: Encourage continued development Patient reported outcomes following ilio-femoral venous stenting (MUC ID: MUC15-411) Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (MUC ID: MUC15-412) Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:A patient-centered outcome measure for a common complication of DVT would be a great addition to the measure set, however, the performance measure must also be tested, not just the assessment instrument. Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms. Preliminary analysis result: Encourage continued development Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (MUC ID: MUC15-412) Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms. Preliminary analysis result: Spreadsheet Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (MUC ID: MUC15-413) Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is very similar and overlapping with MUCFIFTEEN-412 Assessment of post-thrombotic syndrome following ilio-femoral venous stenting – it specifies a different assessment tool. If both tools are useful in assessing the patient, these two measures could be combined into a single measure for better alignment and efficiency of measurement. Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The VCSS “has proved to be a valuable tool for evaluating changes in condition over time with or without intervention”. Preliminary analysis result: Encourage continued development Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (MUC ID: MUC15-413) Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page
10:00 am	Break

10:15 pm	Opportunity for Public Comment on Urogynecology Consent Calendar

10:30 pm	Consent Calendar- Urogynecology

	Reactors: Luther T. Clark (MIPS); James Pacala (MIPS); Barb Landreth (Physician Compare)
	Route of hysterectomy (MUC ID: MUC15-437) Description: Percentage of patients who underwent vaginal hysterectomy (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:The measure provides an intermediate outcome addressing appropriate use and patient safety for a commonly performed surgical procedure for gynecologists. It is unclear what level of performance is desirable and case-mix adjustment may be necessary to make fair comparisons among gynecologists. Impact on quality of care for patients:Hysterectomy is one of the most frequently performed surgical procedures in the US. ACOG concludes that “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications.” 2010 data indicate that hysterectomies are performed vaginally (19%), abdominally (56%), or with laparoscopic (25%) or robotic assistance. ACOG notes that “abdominal hysterectomy is also an important surgical procedure, especially when the vaginal or laparoscopic approach is not appropriate to manage the patient's clinical situation or when facilities cannot support a specific procedure.” While encouraging vaginal hysterectomy as the safer procedure, it is unclear how many patients are not candidates for a vaginal hysterectomy and what the target for this measure should be or whether the patient clinical factors are equally distributed among gynecologists. Preliminary analysis result: Encourage continued development Route of hysterectomy (MUC ID: MUC15-437) Description: Percentage of patients who underwent vaginal hysterectomy (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Patients and other stakeholders are interested in how hysterectomies are performed. Preliminary analysis result: Clinician web page 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: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:The measure adds an appropriate use measure to the group of measures for pelvic prolapse – a common condition in older women. Impact on quality of care for patients: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%. This measure will promote reduced use of mesh and the associated costs (mesh and complications) without affecting patient outcomes. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Testing for uterine disease prior to obliterative procedures (MUC ID: MUC15-439) Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852). (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is a patient safety measure for appropriate work-up prior to surgery for elderly females. Applicable to gynecologists and female pelvic medicine and reconstructive surgery (FPMRS) specialists. Impact on quality of care for patients:The lifetime risk of having surgery for prolapse or incontinence by age 80-85 is 11-19% and projected to increase. Obliterative surgery (colpocleisis) closes the vagina to keep the organs within the pelvis and is an alternative for patients who cannot tolerate extensive surgery and no longer desire preservation of sexual function. Before surgery, work-up should eliminate any co-existing malignant condition before access to the organs is closed off. Data could not be found on the number of these surgeries performed each year. Preliminary analysis result: Encourage continued development Testing for uterine disease prior to obliterative procedures (MUC ID: MUC15-439) Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852). (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Documentation of offering a trial of conservative management prior to fecal incontinence surgery (MUC ID: MUC15-440) Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for fecal incontinence surgery. Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms. Preliminary analysis result: Encourage continued development Documentation of offering a trial of conservative management prior to fecal incontinence surgery (MUC ID: MUC15-440) Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Documentation of offering a trial of conservative management prior to urgency incontinence surgery (MUC ID: MUC15-441) Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for urinary incontinence surgery. Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms. Preliminary analysis result: Encourage continued development Documentation of offering a trial of conservative management prior to urgency incontinence surgery (MUC ID: MUC15-441) Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet
11:30 pm	Opportunity for Public Comment on Gastroenterology Consent Calendar

11:45 pm	Consent Calendar- Gastroenterology

	Reactors: Diane Padden (MIPS); Peter Briss (MIPS); Stephanie Glier (Physician Compare)
	Surveillance endoscopy for dysplasia in Barrett's Esophagus (MUC ID: MUC15-208) Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Though other measure addressing GI endoscopy are in the clinician measure set, none address Barrett’s esophagus. Data on current performance would provide a better understanding of the opportunity for improvement. Impact on quality of care for patients:Barrett’s esophagus is a serious complication occurring in about 10-15% of patients with GERD (reflux).Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's esophagus although less than 1% of patients develop cancer. Nov 2015 guidelinees from American College of Gastroenterology recommend endoscopic surveillance every 3-5 years (strong recommendation, moderate evidence). Preliminary analysis result: Encourage continued development Surveillance endoscopy for dysplasia in Barrett's Esophagus (MUC ID: MUC15-208) Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Surveillance colonoscopy for dysplasia in Ulcerative Colitis (MUC ID: MUC15-221) Description: Percentage of patients with diagnosis of Ulcerative Colitis 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: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:There are no measures that focus on Ulcerative Colitis in the current measures list and this measure would compliment other colonoscopy measures. The registry is not specified. Data on current performance would provide a better understanding of the gap in care. Impact on quality of care for patients:American College of Gastroenterology guidelines state “after 8 – 10 years of colitis, annual or biannual surveillance colonoscopywith multiple biopsies at regular intervals should be performed (Evidence B). Aft er 10 years of universaldisease, the cancer risk has been widely reported in the range of 0.5 – 1 % per year. However, a recent nation-wide population-based analysis from the Netherlands found that 20% of all UC-related cancers were detected before 8 years of diseasehad elapsed. Preliminary analysis result: Encourage continued development Surveillance colonoscopy for dysplasia in Ulcerative Colitis (MUC ID: MUC15-221) Description: Percentage of patients with diagnosis of Ulcerative Colitis 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:There are no measures that focus on Crohn’s Disease in the current measures set and this measure would complement other colonoscopy measures. Data on current performance would provide a better understanding of the gap in care. Registry not specified. Impact on quality of care for patients: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. Early detection of cancer can improve long term survival. ASGE guidelines recommend that patients with Crohn’s Disease for more than 10 years should have a surveillance colonoscopy every 1-2 years Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Non-selective beta blocker use in patients with esophageal varices (MUC ID: MUC15-209) Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Further development is indicated with strong consideration to limit to patients with medium/large varices for which the evidence of benefit of non-selective beta blockers is strong. Testing for reliability and validity at the clinician-level of analysis is needed. The registry is not specified. Impact on quality of care for patients:The 2014 AASLD guidelines recommend use of nonselective beta-blockers to prevent hemorrhage in patients with esophageal varicies but the level of evidence varies depending on the size of the varices: consensus opionion only for small varicies but high level evidence for medium/large varices. As side-effects are significant with these medications patients with small varices might suffer from use of medication for which there is no clear evidence of benefit. Preliminary analysis result: Encourage continued development Non-selective beta blocker use in patients with esophageal varices (MUC ID: MUC15-209) Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet 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: 6 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an intermediate outcome measure related process measure PQRS#087/NQF #0398 Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment. Data on current performance would provide a better understanding of gap in care. Impact on quality of care for patients: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. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 6 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Strong consideration should be given to consolidating this measure as Hepatitis B vaccination for all patients with chronic liver disease, including hepatitis C as recommended by CDC. (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. Impact on quality of care for patients:CDC recommends that all patients with chronic liver disease are vaccinated for hepatitis B. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Impact on quality of care for patients:Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes Preliminary analysis result: Clinician web page 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: 7 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Strong consideration should be given 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. Impact on quality of care for patients:The CDC recommendation for Hepatitis B vaccination includes persons with chronic liver disease as a preventive health measure. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 7 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure must 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. Impact on quality of care for patients: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) Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 4 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set: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. Impact on quality of care for patients: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. Preliminary analysis result: Do not encourage further consideration 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Impact on quality of care for patients:Early detection of varices in cirrhotic patients can improve long term survival Preliminary analysis result: NA 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: 7 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set: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. The registry is not specified. Impact on quality of care for patients:The current evidence indicates that the benefit to patients is uncertain. The costs of screening without evidence of a benefit are not justified. Preliminary analysis result: Do not encourage further consideration 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: Physician Compare Public comments received: 0 Preliminary analysis result: NA
12:30 pm	Lunch

1:45 pm	Opportunity for Public Comment on Miscellaneous Consent Calendar

1:00 pm	Consent Calendar-Miscellaneous

	Reactors: Terry Adirim (MIPS); Winfred Wu (MIPS); Girma Alemu (MIPS); Cynthia Pellegrini (Physician Compare)
	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: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set: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.. Impact on quality of care for patients: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. Preliminary analysis result: Support 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. CONDITION: Successful testing for reliability and validity at the clinician level of analysis and submission of the composite to NQF. Preliminary analysis result: Conditional support 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 2 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the clinician level of analysis. Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs. Preliminary analysis result: Encourage continued development 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: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Potential Opioid Overuse (MUC ID: MUC15-1169) Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 5 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an appropriate use/overuse and patient safety measure that is not duplicative of other measures in the clinician measure set. This MUC directly measures opioid over-prescribing. Data to determine the performance gap is needed. Impact on quality of care for patients:The CDC reports that drug overdoses are the leading cause of injury-related death in the United States and that the death rate from drug overdose has risen dramatically over the last decade. This increase is thought to be attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. There is substantial variation in opioid prescribing patterns across regions and providers, indicating a need for improvement in practices. Preliminary analysis result: Encourage continued development Potential Opioid Overuse (MUC ID: MUC15-1169) Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page HIV Screening for Patients with Sexually Transmitted Disease (STD) (MUC ID: MUC15-230) Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure addresses public health and prevention and is an eMeasure. In 2015 MAP encouraged further development of this measure that is currently in field testing. Patient confidentiality must be considered as a spouse, adult child or adolescent on the family insurance may not want to have HIV testing on the insurance billing and may opt to have the HIV test elsewhere. Impact on quality of care for patients:CDC emphasizes the need for HIV testing for people with STIs as they are considered at higher risk for acquiring HIV. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population Preliminary analysis result: Encourage continued development HIV Screening for Patients with Sexually Transmitted Disease (STD) (MUC ID: MUC15-230) Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (MUC ID: MUC15-296) Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures. (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 3 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This patient safety-focused outcome measure is relevant for anesthesia providers and is not duplicative of other measures in the clinician measure set. Impact on quality of care for patients:Corneal abrasion/injury is a common complication of surgery involving general anesthesia. These injuries are painful for the patient and may lead to other adverse effects, and can also result in increased costs and length of stay. Preliminary analysis result: Encourage continued development New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (MUC ID: MUC15-296) Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures. (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Adverse outcome measures are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page Performance of objective measure of functional hearing status (MUC ID: MUC15-307) Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:The MUC adds another measure for audiologist that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists. Consider strengthening the measure by including counseling the patient, family and caregiver on the results and recommendations of the auditory assessment and report to physician on the need for treatment or further testing. ASHA is building a registry with anticipated completion date of Fall, 2016. Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. Including functional assessment evaluate listening behavior in real world settings - outside the confines of the soundproof booth where most formal audiological testing takes place, may guide management plans, however, it is unclear that evidence supports a relationship with specific patient outcomes. No data on current performance could be found to support an opportunity for improvement. Preliminary analysis result: Encourage continued development Performance of objective measure of functional hearing status (MUC ID: MUC15-307) Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients. Preliminary analysis result: Spreadsheet Patient-Reported Functional Communication (MUC ID: MUC15-313) Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment (Measure Specifications) Programs under consideration: Merit-Based Incentive Payment System (MIPS) Public comments received: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This is an additional measure for audiologists that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists or whether there is an opportunity for improvement. Consider strengthening the measure by using the results of the patient assessment. ASHA is building a registry with anticipated completion date of Fall, 2016. Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. No data on current performance could be found to support an opportunity for improvement. Preliminary analysis result: Encourage continued development Patient-Reported Functional Communication (MUC ID: MUC15-313) Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment (Measure Specifications) Programs under consideration: Physician Compare Public comments received: 0 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:Measures using patient reported data are meaningful to patients and other stakeholders. Preliminary analysis result: Clinician web page 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: 1 Preliminary analysis summary (Full Preliminary Analysis) Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ? Impact on quality of care for patients: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 – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance. Preliminary analysis result: Do not support 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: Physician Compare Public comments received: 0 Preliminary analysis result: NA
2:00 pm	Workgroup Discussion – Gaps in the Clinician program measure sets

2:30 pm	Workgroup Discussion – Alignment
	Alignment of clinician measures across clinician programs; Alignment of clinician measures with measures in hospital and PAC/LTC programs
3:00 pm	Workgroup discussion – Public reporting of clinician measures

3:30 pm	Opportunity for Public Comment

3:45 pm	Summary of the MAP Clinician Workgroup pre-rulemaking input

4:00 pm	Adjourn

Appendix A: Measure Information

Measure Index

Full Measure Information

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

Measure Specifications

NQF Number (if applicable):
Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting
Numerator: All symptomatic patients with stroke or death within 30 days of Carotid Artery Stenting
Denominator: All symptomatic patients undergoing Carotid Artery Stenting
Exclusions: Patients being treated with emergent Carotid Artery Stenting (Acute ischemic stroke or Trauma) Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Multicenter Registry in Hospital/Acute Care Facility
Measure Type: Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Conditional support
Preliminary analysis summary
- Contribution to program measure set:This adverse outcome measure is a “companion” measure to PQRS #345 - Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) and captures a different patient population – those with symptoms (but not acute emergencies.) This measure is intended for interventional radiologists and addresses the quality domain of patient safety. CONDITION: The measure should be submitted to NQF for endorsement.
- Impact on quality of care for patients:Minimizing complications from a procedure is important and comparing complication rates among providers is critical for patients and families when making decisions about healthcare. The American Heart Association and American Stroke Association recommend a complication rate less than 6% for carotid artery stenting. Complication rates higher than 6% negate the potential benefit of stroke risk reduction. The CREST trial, compared stenting to surgery found that there was no significant differences out to four years of follow-up between surgery and carotid stenting when counting all three, but carotid endarterectomy (CEA) has a higher risk of heart attacks and CAS has a higher risk of minor stroke than open surgery.[1] Overall, younger patients (<70 years old) had better outcomes with stenting than with surgery.
Does the measure address a program goal or objective? Yes. This is an adverse outcome measure for carotid artery stenting that is performed to reduce the risk of stroke. The registry-based measure is intended for interventional radiologists
Is this a high-value measure? Yes. The is an adverse outcome and patient safety measure.
Does this measure fill a gap in the program measure set? Yes. This measure adds an adverse outcome measure for a patient group that is not currently measured.
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Group Practice, Community & Academic Hospital environments but whether the testing was done at the individual clinician-level or the facility-level is not reported.
Is the measure currently in use? No. This is a new measure not in use.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Aligns with an existing PQRS measure that measures a related but different population of patients.
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of surgical entropion patients with a postoperative normalized lid position
Numerator: Patients who achieved normalized lid position postoperatively within 90 days of surgery
Denominator: Patients aged 18 years or older with a diagnosis of involutional entropion who underwent a surgical procedure for the condition
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure adds a surgical outcome measure for ophthalmologists, however, It is unclear what the current performance is. As this procedure is sometimes done for cosmetic reasons, a patient-reported outcome would be important also.
- Impact on quality of care for patients:Entropion is an inversion of the eyelid (i.e., inward turning of the eyelid margin) toward the globe. Lower lid entropion is a common condition in elderly individuals; the prevalence increases steadily with age. Involutional entropion is the most common form of entropion. Patients seek treatment due to eye irritation, watering of the eye or cosmetic concerns. Involutional entropion has a prevalence of 2.4% in whites and 0.8% in blacks. No data on current performance could be identified.
Does the measure address a program goal or objective? Yes. This is an outcome measure for a surgical procedure to correct an eye problem common in older adults.
Is this a high-value measure? Yes. This is an outcome measure.
Does this measure fill a gap in the program measure set? Yes. This is a surgical outcome measure for ophthalmologists.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Individual Providers, Group Practice 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells.
Numerator: Patients achieved Grade 0 anterior chamber cells at 30 days after onset of treatment
Denominator: Patients aged 18 years of older who underwent treatment for acute anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Acute Anterior Uveitis: Post-treatment visual acuity.
- Impact on quality of care for patients:The presence of Grade 0 anterior chamber cells indicates reduced inflammation in response to therapy. Though signs of improvement are welcome, the important outcomes are reduction in patient symptoms and good vision.
Does the measure address a program goal or objective? Yes. The is an intermediate outcome measure for a condition not yet represented in the measure set.
Is this a high-value measure? Yes. This is an intermediate outcome measure.
Does this measure fill a gap in the program measure set? Yes. This MUC adds to outcome measures and introduces a new condition for the set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual Providers, Group Practice 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis
Numerator: Best corrected visual acuity of 20/40 or better achieved within 90 days following treatment initiation OR Patient's visual acuity returned to baseline value within 90 days of treatment initiation
Denominator: Patients aged 18 years of older who underwent treatment for acute anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an outcome measure evaluating the effectiveness of treatment for an eye condition not yet represented in the clinician measure set.
- Impact on quality of care for patients:Anterior uveitis is an inflammation of the middle layer of the eye, which includes the iris (colored part of the eye) and adjacent tissue. If untreated, it can cause permanent damage and loss of vision from the development of glaucoma, cataract or retinal edema. It usually responds well to treatment with eye drops. The annual incidence rate is approximately 8 cases per 100,000 population, most commonly in the fourth and fifth decades of life.
Does the measure address a program goal or objective? Yes. The is an outcome measure for a condition not yet represented in the measure set.
Is this a high-value measure? Yes. This is an outcome measure.
Does this measure fill a gap in the program measure set? Yes. This MUC adds to outcome measures and introduces a new condition for the set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual Providers, Group Practice 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting
Numerator: The number of patients who demonstrate an improvement in the Villalta score following ilio-femoral venous stenting as assessed between 3-6 months post procedure
Denominator: The total number of patients who underwent ilio-femoral venous stenting with clinical assessment using the Villalta score at baseline and between 3-6 months post-procedure
Exclusions: Patients with a history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:A patient-centered outcome measure for a common complication of DVT would be a great addition to the measure set, however, the performance measure must also be tested, not just the assessment instrument.
- Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms.
Does the measure address a program goal or objective? Yes. This is an outcome measure assessing improvement in patients’ symptoms after vascular stenting procedure.
Is this a high-value measure? Yes. It is a patient-centered outcome measure.
Does this measure fill a gap in the program measure set? Yes. This is an outcome measure for a common procedure.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? No. Level of Analysis: The Villalta score has been validated as an objective measure to assess post-thrombotic syndrome, an important cause of morbidity in patients with iliofemoral venous disease in group practices. NOTE: This is only testing of the instrument; the performance measure requires testing also for clinicians and groups
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure needs testing for reliability and validity as a performance measure for individuals and groups.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells.
Numerator: Patients achieved Grade 0 anterior chamber cells at 30 days after onset of treatment AND Patients managed at 60 days with dose of topical corticosteroids or prednisolone acetate (or equivalent) 1% 3X/days or less
Denominator: Patients aged 18 years of older who underwent treatment for chronic anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Chronic Anterior Uveitis: Post-treatment visual acuity.
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis
Numerator: Best corrected visual acuity of 20/40 or better achieved within 90 days following treatment initiation OR Patient's visual acuity returned to baseline value within 90 days of treatment initiation
Denominator: Patients aged 18 years of older who underwent treatment for chronic anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an outcome measure for patients with a chronic condition. It is not clear whether patients that fail treatment for acute uveitis in MUCFIFTEEN-394 Acute Anterior Uveitis: Post-treatment visual acuity are the patients in this measure or when the 90 days specified begins.
- Impact on quality of care for patients:Chronic uveitis is active uveitis that persists longer than three months. Chronic anterior uveitis is insidious in onset, persistent, associated with a high incidence of visually threatening complications, and has a variable long term visual prognosis. It may be associated with systemic diseases such as juvenile chronic arthritis, Behçet's disease, and sarcoidosis. The aims of treatment are to control inflammation, prevent visual loss, and minimize long term complications of the disease and its treatment. Maintaining vision is critically important in treating this condition.
Does the measure address a program goal or objective? Yes. The is an outcome measure for a condition not yet represented in the measure set.
Is this a high-value measure? Yes. This is an outcome measure.
Does this measure fill a gap in the program measure set? Yes. This MUC adds to outcome measures and introduces a new condition for the set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual Providers, Group Practice 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious
Numerator: Number of percutaneous arterial access procedures with a vascular complication from common femoral arterial access using a system of 8Fr or less in size including pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious arteritis.
Denominator: All percutaneous groin arterial access procedures using access sheath sizes of 8Fr or less. For patients undergoing bilateral arterial access each access site should be considered a separate event.
Exclusions: Exclusions: Patients with a history of surgical lower extremity bypass. Exceptions: Patients with recent groin arterial access with uncertain vascular access status (i.e. outside arterial procedure, uncertain if complication occurred); Recent arterial vascular access procedure with complication referred for subsequent treatment
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an adverse outcome measure for vascular access performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures.
- Impact on quality of care for patients:Arterial access is performed for a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Clinical guidelines have noted that “modest hematomas from femoral arterial access occur in up to 10% of patients, where as major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable.” Measurement of adverse outcomes provides meaningful information for patients. It is unclear whether the distinction between “modest hematoma” (which does not count in the measure) and “major hematoma” will result in reliable results without better definitions.
Does the measure address a program goal or objective? Yes. This is an outcome measure for arterial access performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures.
Is this a high-value measure? Yes. Adverse outcome measure
Does this measure fill a gap in the program measure set? Yes. Adverse outcome measures are patient safety measures.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level Of Analysis Tested: Group Practice environment, Academic Medical Center, Community Hospital
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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."

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)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less
Numerator: Numerator is the number of patients who completed external beam radiation within 60 days from initiation for locally advanced cervical cancer with curative intent
Denominator: Denominator is the number of women being treated with chemoradiation for locally advanced cervical cancer (ICD-9 180.9; ICD-10 C53.9) Radiation therapy CPT codes 77301, 77338, 77300, 77386, 77295, 77300, 77334, 77412
Exclusions: Women who not being treated with curative intent Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry, Survey
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure is closely related to patient survival. Data on current performance would provide a better understanding of the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:Treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased treatment failure rates and decreased cancer specific and overall survival. If there is a gap in current performance, improved performance would improve patient survival.
Does the measure address a program goal or objective? Yes. This is measure for GYN and GYN ONC that have few measures.
Is this a high-value measure? Yes. This process measure is related to patient outcomes (survival) by solid evidence.
Does this measure fill a gap in the program measure set? Yes. GYN and GYN ONC have few measures
Measure development status: Early Development, Field Testing;
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery
Numerator: Visual acuity of 20/40 of better achieved within 90 days following corneal graft surgery
Denominator: Patients aged 18 years or older who underwent a corneal graft procedure with one of the following indications for surgery: endothelial dystrophy, post cataract surgery edema, failed corneal graft, ectatic disease, anterior/stromal dystrophy, or corneal opacity
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:A functional outcome measure for eye care professionals. Data on current performance would provide better understanding on the opportunity for improvement.
- Impact on quality of care for patients:More than 40,000 corneal transplants or grafts are performed each year in the US. Good vision after any eye procedure is the goal for patients and providers.
Does the measure address a program goal or objective? Yes. This is a functional status (vision) outcome measure.
Is this a high-value measure? Yes. This is an outcome measure.
Does this measure fill a gap in the program measure set? Yes. Although there are eye care measures in the set none address corneal grafts/transplants.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Reported Level of Analysis Tested: Individual Providers, Group Practice. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months
Numerator: Patients who achieved a loss a loss in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of diabetic macular edema who received anti-VEGF injections, intravitreal injections, or laser photocoagulation therapy
Exclusions: Denominator Exclusions: Patients with ophthalmic complications of diabetic retinopathy including neovascular glaucoma, traction retinal detachment, vitreous hemorrhage, history of vitreous surgery, history of retinal surgery, development of retinopathy in the fellow eye Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an outcome measure for a large population at risk of vision loss. Vision loss associated in patients with diabetes can be reduced with good diabetes care. Care coordination among primary and eye care providers is essential to maintain vision.
- Impact on quality of care for patients:Macular edema in common in diabetes. The lifetime risk for diabetics to develop macular edema is about 10%. The condition is closely associated with the degree of diabetic retinopathy (retinal disease). The standard of treatment for diabetic macular edema is glycemic control, optimal blood pressure control, and macular focal/grid laser photocoagulation. New treatments with steroids and anti-VEGF agents are available. Optimal treatment can reduce the risk of vision loss and associated functional limitations in patients with diabetes.
Does the measure address a program goal or objective? Yes. This is an outcome measure for a topic that currently only has process measures.
Is this a high-value measure? Yes. An outcome measure.
Does this measure fill a gap in the program measure set? Yes. Adds to outcome measures in the set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual Providers, Group Practice 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention
Numerator: Number of patients who have been offered conservative management for fecal incontinence prior to surgical intervention. These would be identified by chart review or entry into the PFD Registry. Therapies meeting the criteria for conservative management would include high fiber diet, bulking agents, anti-diarrheal medications for patients with diarrhea, scheduled toileting, Kegel exercises, biofeedback, pelvic floor physical therapy, and fecal disimpaction in patients who are constipated.
Denominator: The number of patients undergoing surgery for the indication of fecal incontinence will be included. Fecal incontinence surgeries will include the following CPT codes: ICD9 0377T anal bulking injection; 46750 for overlapping anal sphincteroplasty, 46761 (anal sphincteroplasty with levator plication), 46762 (ICD10 0DHQ0LZ-0DHQ4LZ) for implantation of artificial anal sphincter, and 64561, 64581, 64590, 77002 for sacral neuromodulation and fecal incontinence will be defined by the following ICD-9/ICD-10 codes: ICD9: 787.60 (full incontinence of feces), 787.62 (fecal smearing), 787.63 (fecal urgency); ICD10: R15.9 (anal sphincter, fecal incontinence); R15.1 (fecal smearing); R15.2 (fecal urgency)
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for fecal incontinence surgery.
- Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms.
Does the measure address a program goal or objective? Yes. This is an additional measure for GYN, FPMRS, Colorectal specialists, though a patient-reported outcome measure would be more meaningful.
Is this a high-value measure? No.
Does this measure fill a gap in the program measure set? No.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: group/individual practices
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS
This measure is intended to 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.

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention
Numerator: Number of patients that who have been offered conservative management for urgency urinary incontinence prior to surgical intervention. These would be identified by chart review or entry into the PFD Registry. Therapies meeting the criteria for conservative management include would include: behavioral modifications (avoiding bladder irritants, excessive fluid intake), Kegel exercises, pelvic floor physical therapy; pharmacologic management.
Denominator: The number of patients undergoing surgery for the indication of urgency urinary incontinence will be included. Urgency incontinence surgeries will include the following CPT codes: ICD9 64566 for posterior tibial nerve stimulation; 64561, 64581, 64590, 77002 for sacral neuromodulation; 52287 chemodenervation-intradetrusor botulinum injections. Urgency incontinence will be defined by the following ICD-9/ICD-10 codes: ICD9: 788.31 (urge incontinence), 788.63 (urinary urgency), 788.41 (urinary frequency), 788.43 (nocturia), 788.33 (mixed urinary incontinence) 788.34 (incontinence without sensory awareness), 788.36 (nocturnal enuresis), 788.37 (continuous leakage), 788.38 (overflow incontinence), 788.39 (other incontinence), 596.59 (detrusor overactivity), 596.54 (neurogenic bladder), 596.51 (overactive bladder). ICD10: N32.81 (overactive bladder), N32.89 (other specified disorders of bladder), N32.9 (other unspecified disorder of bladder), N39.41 (urge incontinence), N39.42 (incontinence w/o sensory awareness), N39.45 (continuous leakage), N39.44 (nocturnal enuresis), N39.46 (mixed incontinence), N39.490(other specified urinary incontinence - reflex or total), N39.498 (total incontinence), R32 (enuresis NOS), R39.81 (urinary incontinence associated with cognitive impairment), R39.81 (functional urinary incontinence)
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for urinary incontinence surgery.
- Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms.
Does the measure address a program goal or objective? Yes. This is an additional measure for GYN and FPMRS
Is this a high-value measure? No. The is a documentation measure – a process remote from patient outcomes.
Does this measure fill a gap in the program measure set? Yes. The measure addresses appropriate management of patients with incontinence prior to considering surgical therapy.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: group/individual practices
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure
Numerator: Number of patients who report symptomatic improvement following uterine artery embolization performed for treatment of fibroids using a disease-specific survey instrument
Denominator: All patients referred for uterine artery embolization who completed a disease specific survey instrument at baseline and 6 months following the procedure.
Exclusions: Exclusions: Patients with incomplete survey data Exceptions: Patients with suspected adenomyosis
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Survey
Measure Type: Patient Reported Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This patient-reported outcome measure provides the patient perspective on the outcome of this procedure for a common condition -- uterine fibroids. This measure is also valuable for public reporting to patients and consumers. It is unclear how the results of the UFS-QOL survey would be submitted to MIPS. It is also unclear whether the UFS-QOL survey is the only acceptable tool – the cost of the survey is $2500.
- Impact on quality of care for patients:Uterine artery embolization (UAE) is an alternative treatment for women with symptomatic fibroids of the uterus. Since the purpose of the procedure is to reduce symptoms, the patient is in the best position to know whether the treatment improved her symptoms or not. Aggregate data from the literature reports that 80-85% of women report improvement in their symptoms. UAE avoids the risks of major surgery (hysterectomy) though the costs are similar. 20% of patients require additional treatment after UAE. If UAE is promoted as a less invasive, safer treatment than traditional surgery, it is important to know that the results for patients are good.
Does the measure address a program goal or objective? Yes. This measure meets CMS’s priority for patient reported outcome measures. The measure is for interventional radiologists in a new topic area and addresses the quality domain of patient experience.
Is this a high-value measure? Yes. This is a patient reported outcome measure (PRO).
Does this measure fill a gap in the program measure set? Yes. There are few PROs in the measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at the Group Practice environment, Academic Medical Center, Community Hospital but whether the testing was done at the individual clinician-level or the facility-level is not reported.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? N/A. No similar measures are in use.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months
Numerator: Patients who achieved a lost in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of exudative age-related macular degeneration being treated with anti-vegf agents
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an outcome measures for a topic with only process measures currently. Since AMD is a slowly progressive condition, it is unclear whether this outcome measure is a function of the natural progression of the disease and to what extent clinical management will influence the outcome.
- Impact on quality of care for patients:There is an estimated 1.75 million cases of advanced AMD in the US. AMD is the leading cause of irreversible visual loss in the United States, with variable degrees of age-related macular changes occurring in more than 10% of the population aged 65-74 years and 25% of the population older than 74 years. Therapy with anti-VEGF agents is the gold standard with promising results, many intravitreal injections are often required, and they do not cure all cases of wet (neovascular) AMD. A Mayo Clinic study reported that “the anti-VEGF therapy yielded improved best-corrected visual acuity. “
Does the measure address a program goal or objective? Yes. This is an outcome measure – there are no other outcome measures for macular degeneration in the clinician set. ?
Is this a high-value measure? Yes. This is an outcome measure for a condition prevalent in the Medicare population.
Does this measure fill a gap in the program measure set? Yes. Although there are a few measures for eye care, there are no outcome measures for macular degeneration.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? No. The MUC is still in development. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. This is an outcome measure – no other outcome measures for macular degeneration in the clinician set. ?
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition
Numerator: Patient visits where the eye(s) intraocular pressure (IOP) was below a specified threshold based on the severity of their glaucoma. - Mild stage glaucoma: IOP <= 22mm HG - Moderate stage glaucoma: IOP <= 18 mm HG - Severe stage: IOP <= 15 mm HG
Denominator: Patients aged between 40 and 85 years, with a minimum of 4 office visits during the prior 24 months, with a diagnosis of glaucoma and with documentation of the severity of their condition.
Exclusions: Denominator Exclusions: Patients with a diagnosis of low tension glaucoma OR Eyes with a documented severity of indeterminate stage OR Eyes with absolute glaucoma blindness OR Patients who had glaucoma incisional surgery performed within the last 90 days OR Patients with visual acuity findings of count fingers, hand motion, light perception or no light perception Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This intermediate outcome measure is very similar to PQRS # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care. This new MUC might be an improvement on PQRS #141.This MUC differentiates the outcome threshold based on severity of disease and does not have the plan of care component. No information regarding the targets specified in this measure could be identified nor evidence that these targets are related to specific outcomes.
- Impact on quality of care for patients:There are approximately 4 million Americans with glaucoma – 200,000 are severely visually impaired. Reduction of intraocular pressure (IOP) has been shown to effectively reduce the risk of glaucoma progression. American Association of Ophthalmology guidelines recommend “The goal of glaucoma treatment is to maintain the IOP in a range at which a patient is likely to remain stable or at which worsening of glaucoma will be slow enough that the risk of additional intervention is not justified. The target pressure should be individualized and may need adjustment during the course of the disease.” Evidence level A:III.
Does the measure address a program goal or objective? Yes. This is an intermediate outcome measure for a common condition in the Medicare population. This registry measure addresses the domain of clinical care.
Is this a high-value measure? Yes. This is an intermediate outcome measure. This measure is also disparities sensitive because the prevalence of POAG is higher in individuals of West African, Afro-Caribbean, or Latino/Hispanic origin than of other groups.
Does this measure fill a gap in the program measure set? Yes. This outcome may be an improvement on the existing PQRS # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care. This MUC differentiates the outcome threshold based on severity of disease.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual Providers, Group Practice. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No. New measure being tested.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This outcome measure is very similar to PQRS # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care. This new MUC might be an alternative to PQRS #141 – both would not be needed in the final set.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level.
Numerator: Patients eyes with a reduction in intraocular pressure = 20% from their pretreatment level
Denominator: Patients aged between 40 and 85 years who underwent laser trabeculoplasty
Exclusions: Denominator Exclusions: Eyes with absolute glaucoma blindness OR Patients with visual acuity findings of count fingers, hand motion, light perception or no light perception Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an additional outcome measure for patients undergoing laser surgery for glaucoma. Clarification of the timing of the post-operative pressure measurement is needed.
- Impact on quality of care for patients:Surgery is used when medications fail to control vision loss caused by glaucoma. Laser surgery is done more often than conventional surgery. The most common complication from laser surgery for glaucoma is increased pressure within the eye that may rise sharply 1-4 months after surgery. The measure does not specify a timeframe for measuring the IOP after surgery– if performed too soon the measure may not capture increased pressures that occur several months after surgery and would over estimate good outcomes.
Does the measure address a program goal or objective? Yes. This is an intermediate outcome measure for laser treatment of glaucoma, a common condition in the Medicare population.
Is this a high-value measure? Yes. This is an intermediate outcome measure.
Does this measure fill a gap in the program measure set? Yes. Although there are several glaucoma measures in the set, this outcome measure addresses a more severely affected population and the outcome of a surgical intervention.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure is being tested for ambulatory/office-based care. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This intermediate outcome measure could replace existing processes measures and is aligned with other glaucoma measures..
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis A vaccination
Numerator: Patients with diagnosis of cirrhosis who have had a hepatitis A vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis A vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure must 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.
- Impact on quality of care for patients: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)
Does the measure address a program goal or objective? Yes. This MUC addresses a new topic area of cirrhosis and adds a measure for liver specialist that have few measures.
Is this a high-value measure? Yes. The is a population health/prevention measure.
Does this measure fill a gap in the program measure set? Yes. This is a new topic area.
Measure development status: Field Testing – level of analysis not specified
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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)

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of chronic Hepatitis C that have documented hepatitis B vaccination
Numerator: Patients with diagnosis of chronic Hepatitis C who have had a hepatitis B vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of chronic Hepatitis C
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis B vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: A similar measure was not endorsed by NQF because it specified only receipt of the first dose of vaccine which is not thought to be adequate for protection.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:Strong consideration should be given to consolidating this measure as Hepatitis B vaccination for all patients with chronic liver disease, including hepatitis C as recommended by CDC. (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.
- Impact on quality of care for patients:CDC recommends that all patients with chronic liver disease are vaccinated for hepatitis B.
Does the measure address a program goal or objective? Yes. Adds another population health and prevention measure for hepatitis C.
Is this a high-value measure? Yes. Population health and prevention measure.
Does this measure fill a gap in the program measure set? Yes. Related-PQRS# 183 Hepatitis C: Hepatitis A Vaccination. Steward is AGA
Measure development status: Field Testing –level of testing not specified
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. A similar measure was not endorsed by NQF because it specified only receipt of the first dose of vaccine which is not thought to be adequate for protection.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis B vaccination
Numerator: Patients with diagnosis of cirrhosis who have had a hepatitis B vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis B vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:Strong consideration should be given 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.
- Impact on quality of care for patients:The CDC recommendation for Hepatitis B vaccination includes persons with chronic liver disease as a preventive health measure.
Does the measure address a program goal or objective? Yes. This MUC addresses a new topic area of cirrhosis and adds a measure for liver specialist that have few measures.
Is this a high-value measure? No. The CDC recommendation for Hepatitis B vaccination includes persons with chronic liver disease – should expand the measure to the largest population recommended by CDC.
Does this measure fill a gap in the program measure set? No.
Measure development status: Field Testing – level of analysis not specified
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. Recommend expanding to include all chronic liver disease, including hepatitis C.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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)

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

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Patients with undetectable HCV RNA 11 weeks after cessation of treatment
Denominator: All patients aged 18 years and older with a diagnosis of hepatitis C who are initiating or receiving antiviral treatment during the measurement period
Exclusions: Measure only needs to be reported if initiation of antiviral treatment took place before October of the measurement year (11 weeks before the end of the measurement period)
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Gastroenterological Association
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an intermediate outcome measure related process measure PQRS#087/NQF #0398 Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment. Data on current performance would provide a better understanding of gap in care.
- Impact on quality of care for patients: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.
Does the measure address a program goal or objective? Yes. This is an intermediate outcome measure related process measure PQRS#087/NQF #0398 Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment.
Is this a high-value measure? Yes. This is a outcome measure.
Does this measure fill a gap in the program measure set? Yes. Although there are several endorsed and fully tested Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) measures in the current measure list, this is an outcome measure for Hepatitis C.
Measure development status: Early Development
Is the measure fully tested for the program's setting and level of analysis? Details of testing not provided.
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. The outcome measure could replace several existing process measures.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV
Numerator: Patients with an HIV test during period extending from 30 days before STD diagnosis to 30 days after STD diagnosis
Denominator: Patients diagnosed with an acute STD during the one year period ending 30 days prior to the end of the measurement year. STDs include: syphilis and gonorrhea
Exclusions: Denominator Exclusions: Patients who have HIV infection.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Measure designed so that all relevant data should be available/abstractable from EHR
Measure Type: Process
Steward: Centers for Disease Control and Prevention
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure addresses public health and prevention and is an eMeasure. In 2015 MAP encouraged further development of this measure that is currently in field testing. Patient confidentiality must be considered as a spouse, adult child or adolescent on the family insurance may not want to have HIV testing on the insurance billing and may opt to have the HIV test elsewhere.
- Impact on quality of care for patients:CDC emphasizes the need for HIV testing for people with STIs as they are considered at higher risk for acquiring HIV. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population
Does the measure address a program goal or objective? Yes. Addresses public health and prevention.
Is this a high-value measure? Yes. eCQM measure (MAT #329)
Does this measure fill a gap in the program measure set? Yes. eMeasure (eCQM) and Population Health measure
Measure development status: Currently in Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Has been preliminary tested in a group of Chicago-based FQHCs.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS
Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The 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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting
Numerator: The number of patients who demonstrate improvement in the venous clinical severity score following ilio-femoral venous stenting as assessed 3-6 months post-procedure
Denominator: The total number of patients who underwent ilio-femoral venous stenting with application of the venous clinical severity both at baseline and at 3-6 months post-procedure.
Exclusions: Patients with history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Intermediate Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Endorsed
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure is very similar and overlapping with MUCFIFTEEN-412 Assessment of post-thrombotic syndrome following ilio-femoral venous stenting – it specifies a different assessment tool. If both tools are useful in assessing the patient, these two measures could be combined into a single measure for better alignment and efficiency of measurement.
- Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The VCSS “has proved to be a valuable tool for evaluating changes in condition over time with or without intervention”.
Does the measure address a program goal or objective? Yes. This is an outcome measure.
Is this a high-value measure? Yes. This is an outcome measure
Does this measure fill a gap in the program measure set? Yes. This is an outcome measure to assess effectiveness of treatment procedure.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis tested: Group Practice, Academic medical centers
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No . This measure is very similar and overlapping with MUCFIFTEEN-412 Assessment of post-thrombotic syndrome following ilio-femoral venous stenting
Is the measure NQF endorsed for the program's setting and level of analysis? No. Endorsed

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer
Numerator: Patients who have Ovarian cancer / fallopian tube cancer ( ICD-9= 183.0 (Ovarian cancer) 183.2 (Fallopian tube cancer) AND received IP chemo within 42 days from surgery
Denominator: All patients who underwent debulking surgery for ovarian cancer. CPT coding may vary but possibilities are: 58950 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy 58951 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphandenectomy 58952 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) 58953 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking 58954 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphandenectomy and limited para-aortic lymphadenectomy 58956 – Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 58957 – Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed 58958 - Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
Exclusions: Patients who received Neoadjuvant Chemotherapy Patients with non-epithelial cancer Patients who had the IP chemotherapy not offered (and or to be offered IP chemotherapy after the first cycle of IV chemotherapy) by the surgeons for any of the listed reasons: a- Those who had bowel resection as part of their debulking surgery. b- Had multiple abdominal surgeries that impede the futility of IP chemotherapy. c- Patients’ who have had a sub optimal debulking d- Any other medical reason(s) that contraindicated IP chemotherapy (e.g.: peritonitis, inflammatory bowel disease, liver failure, renal failure. etc.) Exceptions: Patients who are pregnant at the time of diagnosis ( ICD-9= 640.0 – 669.9 and V22.0 – V23.9)
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:There is no information that there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:It is unclear how many patients are not receiving this standard of care. The impact of the measure is limited if current performance is very high.
Does the measure address a program goal or objective? No. This is an appropriateness and timeliness measure for ovarian cancer care for GYN and GYN Oncologists, although there is no information that patients are not receiving this standard of care or that there is any opportunity for improvement.
Is this a high-value measure? Yes. This measure assesses whether ovarian cancer patients are receiving the highest standard of care.
Does this measure fill a gap in the program measure set? Yes. There are few measure for GYN cancer care.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

Measure Specifications

NQF Number (if applicable):
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
Numerator: Most recent BP is less than 140/90 mm Hg And Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure) And Daily Aspirin or Other Antiplatelet Unless Contraindicated And Statin Use
Denominator: Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the Measurement Period. A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months.
Exclusions: History of Gastrointestinal Bleed or Intra-cranial Bleed or documentation of active anticoagulant use during the MP for the Aspirin/Other Anticoagulant component (numerator) of the measure. Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) for the Blood Pressure Control component (numerator) of the composite measure.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Wisconsin Collaborative for Healthcare Quality (WCHQ)
Endorsement Status: The NQF Cardiovascular Standing Committee has deferred endorsement recommendation on this measure until they can evaluate it side-by-side with NQF#0076 Optinal Vascular Care.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Do not support
Preliminary analysis summary
- Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ?
- Impact on quality of care for patients: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 – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance.
Does the measure address a program goal or objective? No. This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ?
Is this a high-value measure? Yes. This is a composite measure
Does this measure fill a gap in the program measure set? No.
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure was tested at the clinician and group level of analysis. Testing data presented in the NQF submission reported testing of 121 clinic sites of 50, 758 patients. Signal-to-noise reliability estimates for the measure score was 0.78 (generally accepted to be sufficient for determining performance differences between groups.)
Is the measure currently in use? Yes. 2014 performance data for 121 clinics, covering a total of 42,290 patients in Wisconsin found the average clinic performance to be 59% (range 38-75%) – the 90th percentile is 67%. WCHQ publicly reports performance information on group practices and clinics participating in the collaborative; this includes 17 organizations reporting at the group practice level and 121 at the clinic site level, for a total of 50,758 patients.
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ?
Is the measure NQF endorsed for the program's setting and level of analysis? No. The NQF Cardiovascular Standing Committee has deferred endorsement recommendation on this measure until they can evaluate it side-by-side with NQF#0076 Optinal Vascular Care.

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer
Numerator: Number of patients with endometrial cancer (ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 Other specified sites of body of uterus) who underwent minimally invasive hysterectomy. Minimally invasive is defined as laparoscopic or robotic approaches (CPT codes: 58541-44, 58550, 58552-54, 58570-73) with or without vaginal assistance (58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-94).
Denominator: Number of patients with endometrial cancer (ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 Other specified sites of body of uterus) who underwent hysterectomy. This includes hysterectomy via laparotomy (58150, 58152, 58180, 58200, 58210), laparoscopy, robotic, or vaginal (see CPT codes in numerator).
Exclusions: Patients with endometrial cancer who did not undergo hysterectomy Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an surgical appropriateness measure for uterine cancer care for GYN and GYN ONC. There are no other measures for endometrial cancer – an important condition in the Medicare population. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:Studies show that minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) has no difference in survival compared to open surgery, but patients undergoing minimally invasive surgery had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks. Measure submitter reports that data indicates variation in performance of 50-90%. Improvement in this measure would improve the quality of care for patients with endometrial cancer and reduce costs.
Does the measure address a program goal or objective? Yes. This is an appropriateness measure for endometrial (uterine) cancer care for GYN and GYN ONC.
Is this a high-value measure? Yes. This is an appropriateness of surgical care measure.
Does this measure fill a gap in the program measure set? Yes. There are no other measures for endometrial cancer – a high-volume condition in the Medicare population.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures.
Numerator: All patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area Definition: Corneal Injury: Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded.
Denominator: All patients who undergo anesthesia care, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery.
Exclusions: Exclusions: none Exceptions: Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury before anesthesia care.
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Society of Anesthesiologists
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This patient safety-focused outcome measure is relevant for anesthesia providers and is not duplicative of other measures in the clinician measure set.
- Impact on quality of care for patients:Corneal abrasion/injury is a common complication of surgery involving general anesthesia. These injuries are painful for the patient and may lead to other adverse effects, and can also result in increased costs and length of stay.
Does the measure address a program goal or objective? Yes. As an outcome measure that is relevant for anesthesiologists.
Is this a high-value measure? Yes. This is a patient safety-focused, outcome measure.
Does this measure fill a gap in the program measure set? Yes. There are a limited number of patient safety-related outcome measures in the measure set, and only one that is specific to anesthesiology.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? As reported by the measure submitter, field testing is currently being performed for the appropriate settings and levels of analysis.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This is an outcome measure that is not duplicative of other measures in the MIPS program.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 5 business days from the time when the tissue specimen was received by the pathologist.
Denominator: All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease).
Exclusions: Pathologists/Dermatopathologists providing a second opinion on a biopsy.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:A measure that evaluates the reporting time between pathologist and biopsying clinician should not be restricted to dermatology biopsies. Strong consideration should be given to expanding this communication measure to all biopsies. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Data on current performance is needed to understand the gap in care.
- Impact on quality of care for patients:Timely pathology reports are essential to inform the patient and plan treatment. Patients should expect a timely report on the results of any biopsy. Delays or lost reports are potentially quite costly. Effective and timely communication between the two practitioners is essential to ensuring timely and effective patient care.
Does the measure address a program goal or objective? Yes. An additional measure for pathologists
Is this a high-value measure? Yes. This is a communication and care coordination measure.
Does this measure fill a gap in the program measure set? Yes. There are few communication measures in the clinician measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual practice, group practice, University hospital setting (Academic). The measure is in testing now with results expected in Summer - Fall 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months
Numerator: Patients who achieved a loss a loss in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of nonexudative AMD and taking AREDS supplements
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This MUC is an outcome measure for a condition that only has process measures. It is unclear whether the degree of vision change quantified in this measure will reflect the natural slow progression of the disease or the impact of optimal treatment to slow down disease progression.
- Impact on quality of care for patients:Non-exudative AMD comprises more than 90% of patients with AMD and generally has a much slower (over decades), progressive visual loss relative to exudative (wet) AMD). There is currently no cure for AMD, but treatments may prevent severe vision loss or slow the progression of the disease considerably. Not all patients with AMD are candidates for use of the AREDS vitamin formulation. Taking the AREDS vitamins was shown to reduce the risk of advanced AMD by 25%.
Does the measure address a program goal or objective? Yes. This is an outcome measure – no other outcome measures for macular degeneration in the clinician set. ?
Is this a high-value measure? Yes. This is an outcome measure for a condition prevalent in the Medicare population.
Does this measure fill a gap in the program measure set? Yes. Although there are a few measures for eye care, there are no outcome measures for macular degeneration.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? No. The MUC is still in development. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient.
Numerator: Number of cutaneous biopsies by the clinician consistent with basal cell carcinoma or squamous cell carcinoma (to include in situ disease) for which the patient was notified of their final biopsy pathology findings within 15 business days from the time when the biopsy was performed. Distinct dates of service resulting in an eligible patient procedure should be reported separately.
Denominator: All cutaneous biopsies by the clinician consistent with cutaneous basal or squamous cell carcinoma (including in situ disease).
Exclusions: Pathology reports for tissue specimens produced from excision.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure adds a communication measure. Data on current performance would provide a better understanding of the gap in care. . This patient centered-communication measure should be expanded to include all biopsies performed by any clinician for any condition. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
- Impact on quality of care for patients:Patients should expect a timely report on the results of any biopsy. There are more new cases of skin cancer reported each year than cancers of the breast, prostate, lung and colon combined (http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf).The most common types of skin cancer are basal cell and squamous cell skin cancer, most commonly referred to as non-melanoma skin cancer or NMSC. The most recent study from 2006 estimated 3.5 million cases of NMSC were diagnosed from 2.2 million people. Currently, pathology reports are received by the biopsying clinician within 10 days after the biopsy is performed (cancer.org) and even longer for the clinician to share the results with the patient. Effective and timely communication between the clinician and patient is essential to ensuring safe and effective patient care along with reducing cost.
Does the measure address a program goal or objective? Yes. This is a patient centered measure addressing communication. Data on current performance/gap in care is not provided.
Is this a high-value measure? Yes. This is a patient-centered, communication measure.
Does this measure fill a gap in the program measure set? Yes. There are few communication measures in the clinician measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual practice, group practice, University hospital setting (Academic) Setting of Measure Testing: Office- Based Care, Hospital Setting (Academic, Dermatology). The measure is in testing now with results expected in Summer - Fall 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening.
Numerator: Patients who receive a PSA-based screening test during the measurement period.
Denominator: Men of any age with an encounter during the measurement period.
Exclusions: Denominator exclusions: Men who had an active diagnosis or history of prostate cancer diagnosis, an active diagnosis of dysplasia of the prostate, or an elevated PSA test result in the year prior to the measurement period (>4.0 nanograms/milliliter [ng/mL]).
HHS NQS Priority: Making Care Safer
HHS Data Source: This measure is intended to be an electronic Clinical Quality Measure (eCQM) and will use EHR data exclusively.
Measure Type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure fills a need for appropriate use/overuse measures that apply to a broad population of patients.
- Impact on quality of care for patients: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. Unnecessary screening tests are costly and create unnecessary anxiety and follow up evaluations for patients.
Does the measure address a program goal or objective? Yes. This is an appropriate use measure, a population health measure and an eCQM (eMeasure).? No information on performance gap is provided though criticisms of the USPSTF recommendation against PSA screening indicates there are clinicians who support PSA screening.
Is this a high-value measure? Yes. This measure addresses overuse of PSA screening.
Does this measure fill a gap in the program measure set? Yes. No measures currently address PSA screening.
Measure development status: Early Development
Is the measure fully tested for the program's setting and level of analysis? No. The measure has not been tested yet.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. The measure addresses overuse in a new, important area.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period
Numerator: Patients with diagnosis of esophageal varices on non-selective beta blocker in the measurement period
Denominator: All patients with diagnosis of esophageal varices
Exclusions: Exclusions: none Exceptions: Intolerance to non-selective beta blocker, pulse < 60, systolic BP < 90, diastolic BP < 50
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Further development is indicated with strong consideration to limit to patients with medium/large varices for which the evidence of benefit of non-selective beta blockers is strong. Testing for reliability and validity at the clinician-level of analysis is needed. The registry is not specified.
- Impact on quality of care for patients:The 2014 AASLD guidelines recommend use of nonselective beta-blockers to prevent hemorrhage in patients with esophageal varicies but the level of evidence varies depending on the size of the varices: consensus opionion only for small varicies but high level evidence for medium/large varices. As side-effects are significant with these medications patients with small varices might suffer from use of medication for which there is no clear evidence of benefit.
Does the measure address a program goal or objective? Yes. This measure addresses a new topic area and provides an additional measure for gastroenterologists.
Is this a high-value measure? No. The evidence for this measure in some patients is low.
Does this measure fill a gap in the program measure set? Yes. There are no measures that focus on esophageal varices in the current measures list.
Measure development status: Field Testing – level of testing unknown
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.
Numerator: Number of patients undergoing surgery for pelvic organ prolapse in the posterior compartment with a synthetic mesh augment is placed in the posterior compartment.
Denominator: Number of patients undergoing surgery for pelvic organ prolapse which includes the posterior compartment. The prolapse codes for ICD9 -> ICD-10 include: 618.04 -> N81.6, Rectocele
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:The measure adds an appropriate use measure to the group of measures for pelvic prolapse – a common condition in older women.
- Impact on quality of care for patients: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%. This measure will promote reduced use of mesh and the associated costs (mesh and complications) without affecting patient outcomes.
Does the measure address a program goal or objective? Yes. This is an appropriate use measure addressing a surgery for pelvic prolapse –a common condition in older women.?
Is this a high-value measure? Yes. This is an appropriate use (overuse) measure.
Does this measure fill a gap in the program measure set? Yes. Although other measures for pelvic prolapse are proposed, none are appropriate use measures.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Reported tested at the individual/group level of analysis in the hospital setting.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable): 2103
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.
Numerator: 712: Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during the four month measurement period. #711: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five. #710: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.
Denominator: 712: Adult patients age 18 and older with the diagnosis of major depression or dysthymia. #711: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine. #710: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine.
Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: EHR, Paper medical record
Measure Type: Outcome
Steward: MN Community Measurement
Endorsement Status: Never Submitted
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Support
Preliminary analysis summary
- Contribution to program measure set: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..
- Impact on quality of care for patients: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.
Does the measure address a program goal or objective? Yes. It is a fully developed and tested eCQM that does not duplicate other measures currently in the MIPS
Is this a high-value measure? Yes. Three paired measures, two of which are PROs and currently used in PQRS.
Does this measure fill a gap in the program measure set? Yes. Fills the CMS high-priority domain of person and caregiver-centered experience and outcomes measures
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Setting tested: Ambulatory/office-based care Level of analysis: Clinician, Group, Facility The MIF states the measure was only tested at the group level.
Is the measure currently in use? Yes. Finalized Public Programs: CMS eHR Incentive Program (Meaningful Use of Health Information Technology MU2 Stage 2)Federal Programs Under Consideration: None Private: MN HealthScores
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Currently in MUNon-duplicative paired measure
Is the measure NQF endorsed for the program's setting and level of analysis? Yes. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting
Numerator: The number of patients who demonstrate improvement on a disease-specific patient reported quality of life score at 3-6 months following ilio-femoral venous stenting
Denominator: The total number of patients undergoing ilio-femoral venous stenting who received a baseline and follow-up disease specific patient reported quality of life score at 3-6 months
Exclusions: Patients with a history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure Type: Patient Reported Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This PRO adds important information for public reporting and quality of care that is meaningful to patients and their families. The measure is intended for interventional radiologists. No information is provided on cost of the survey and it is unclear how the survey results will be transmitted to MIPS.
- Impact on quality of care for patients:Ilio-femoral vein stenting has become a safe and effective alternative to traditional open surgery to correct iliac vein obstruction. A RAND evidence review in 2013 reported relief of pain (86-94%), relief from swelling (66%-89%) and healing of venous ulcers (55-89%) in published studies. The RAND summary concluded the benefits outweigh the risks (1B). This PRO can provide important information on performance for patients and other stakeholders seeking information on outcomes from the patient perspective and high-quality care.
Does the measure address a program goal or objective? Yes. This is a patient-reported outcome. This MUC is intended for interventional radiologists and addresses the domain of patient experience.?
Is this a high-value measure? Yes. Patient-reported outcomes provide valuable information for patients and consumers when selecting healthcare providers.
Does this measure fill a gap in the program measure set? Yes. There are few PROs in the measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Reliability testing is available for multiple disease-specific quality of life scores in group practice, academic medical center, community hospital setting – whether testing is at the individual clinician, group or facility is not reported. Testing results are not provided.
Is the measure currently in use? No. This is a new measure.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment
Numerator: A standardized, patient-reported functional communication assessment is documented in the record
Denominator: Patients age 18 years and older on the date of the encounter with a diagnosis of a permanent, bilateral sensorineural hearing loss (ICD-10 H90.3, H91.03, H91.3) and are seen for audiologic testing (CPT 92552, 92553, 92557, 92591, 92626)
Exclusions: 1) Patient has a hearing loss that requires medical or surgical intervention 2) Patient refuses to participate/complete patient-reported functional hearing assessment 3) Patient is unable to perform functional hearing assessment due to other complicated health factors, language delay, or developmental delay Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: AQC/ASHA
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an additional measure for audiologists that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists or whether there is an opportunity for improvement. Consider strengthening the measure by using the results of the patient assessment. ASHA is building a registry with anticipated completion date of Fall, 2016.
- Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. No data on current performance could be found to support an opportunity for improvement.
Does the measure address a program goal or objective? Yes. An additional measure for audiologists that have few measures in the current set.
Is this a high-value measure? No. This is a documentation measure but does not use the patient-reported information.
Does this measure fill a gap in the program measure set? Yes. An additional measure for audiologists that have few measures in the current set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Testing at the group and facility level. Testing is expected to be completed by Fall 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition
Numerator: An objective measure of functional hearing status using a standardized open-set speech recognition test (words, short phrases, or sentences) is documented.
Denominator: Patients age 5 years and older on the date of the encounter diagnosed with a permanent, bilateral sensorineural hearing loss (ICD-10: H90.3, H91.03, H91.3) and seen for audiologic testing (CPT 92552, 92553, 92557, 92579, 92582, 92591, 92626)
Exclusions: 1) Patient has a hearing loss that requires medical or surgical intervention 2) Patient refuses to participate 3) Patient is unable to perform functional hearing assessment due to other complicated health factors, language delay or developmental delay. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Audiology Quality Consortium/American Speech Language Hearing Association
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:The MUC adds another measure for audiologist that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists. Consider strengthening the measure by including counseling the patient, family and caregiver on the results and recommendations of the auditory assessment and report to physician on the need for treatment or further testing. ASHA is building a registry with anticipated completion date of Fall, 2016.
- Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. Including functional assessment evaluate listening behavior in real world settings - outside the confines of the soundproof booth where most formal audiological testing takes place, may guide management plans, however, it is unclear that evidence supports a relationship with specific patient outcomes. No data on current performance could be found to support an opportunity for improvement.
Does the measure address a program goal or objective? Yes. Additional measure for audiologists that have few measures in their current set.
Is this a high-value measure? No. This is a documentation measure.
Does this measure fill a gap in the program measure set? Yes. Adds a measure for audiologists that have few measures.
Measure development status: Early Development
Is the measure fully tested for the program's setting and level of analysis? Testing is expected to be completed by Fall 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy.
Numerator: Women whose hysterectomy is classified as a radical hysterectomy and includes removal of parametrial tissue, vaginal tissue and a portion of the uterosacral ligaments. CPT 58210, 58285, or ICD9 codes 68.6, 68.61, 68.69, 68.7, 68.71, 68.79
Denominator: Women with histologically confirmed stage IB1-IIA cervical cancer who undergo hysterectomy. CPT codes 58210, 58285, 58150, 58152, 58180, 58200, 58956, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58572, 58571, 58573, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294 or ICD9 codes 68.6, 68.61, 68.69, 68.7, 68.71, 68.79, 68.3, 68.31, 68.39, 68.4, 68.41, 68.49, 68.5, 68.51, 68.59, 68.6, 68.61, 68.69, 68.9
Exclusions: Women who undergo primary surgery that is not a hysterectomy. Women who undergo secondary surgery after primary radiotherapy or chemoradiation. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:Data on current performance is needed to assess whether there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:Radical hysterectomy is the standard procedure for women who undergo surgical treatment for cervical cancer. This is a more extensive surgery aimed at curing the cancer. If most women are receiving this standard of care, there will be little improvement from use of this measure.
Does the measure address a program goal or objective? Yes. The measure addresses a new topic area for clinician measurement – cervical cancer care for GYN and GYN ONC physicians that have few measures.?
Is this a high-value measure? Yes. Appropriate use of radical hysterectomy for patients with cervical cancer who undergo surgery.
Does this measure fill a gap in the program measure set? Yes.
Measure development status: Early Development, Field Testing NOTE: Need data on current performance/
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices.Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer
Numerator: Patients who have Ovarian cancer / fallopian tube cancer ( ICD-9= 183.0 (Ovarian cancer) 183.2 (Fallopian tube cancer) AND received IV chemo within 42 days from surgery
Denominator: All patient who underwent debulking surgery for ovarian cancer. CPT coding may varies but those are the possibilites.58950 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy 58951 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphandenectomy 58952 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) 58953 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking 58954 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphandenectomy and limited para-aortic lymphadenectomy 58956 – Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 58957 – Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed 58958 - Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
Exclusions: Patients who received Neoadjuvant Chemotherapy Patients with non-epithelial cancer Exceptions: Patients who are pregnant at the time of diagnosis ( ICD-9= 640.0 – 669.9 and V22.0 – V23.9)
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:Currently there are few measures for ovarian cancer and GYN ONC specialists, however, there is no evidence that patients are not receiving this standard of care – the opportunity for improvement may be limited. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma according to analysis of patient data in the prospective OVCAD study. (Gynecologic oncology. 2013;131:15-20. PMID= 23877013). However, the impact is limited if there is no opportunity for improvement.
Does the measure address a program goal or objective? Yes. Currently there are few measures for ovarian cancer and GYN ONC specialists, however, there is no evidence that patients are not receiving this standard of care – the opportunity for improvement may be limited.
Is this a high-value measure? No.
Does this measure fill a gap in the program measure set? Yes. There are few measures for ovarian cancer care.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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).

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)

Measure Specifications

NQF Number (if applicable):
Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy)
Numerator: Cervical cancer: 180.0, 180.1, 180.9, parametrium 183.4, vagina 184.0, Positive lymph nodes draining the cervical basin secondary : ICD9 codes 196.2, 196.6, 197.6, radiation therapy CPT codes: IMRT 77418, 0073T, HDR brachy 77785-77787,
Denominator: Cervical cancer: 180.0, 180.1, 180.9 , parametrium 183.4, vagina 184.0, Positive lymph nodes draining the cervical basin secondary : ICD9 codes 196.2, 196.6, 197.6
Exclusions: Small cell, melanoma and other cervical histologies that might be treated with primary chemotherapy. Secondary cervical cancers Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Endorsed; MUC same as endorsed version: Yes; NQF endorsement review - 2015
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:As combination therapy is the standard of care for patients with spread of cervical cancer beyond surgical margins, it is unclear whether there is an opportunity for improvement. Unless data can demonstrate there is a gap in care, this measure will add little to the current set. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:The National Cancer Institute recommends that platinum containing chemotherapy be added to post-operative radiation therapy for patients with tumor spread beyond the cervix. If patients are receiving this standard of care treatment, little additional gain is likely from use of this measure.
Does the measure address a program goal or objective? Yes. This a measure for cervical cancer – a new topic area for the set. There is no data on current performance to understand the opportunity for improvement for this standard of care.
Is this a high-value measure? No.
Does this measure fill a gap in the program measure set? Yes. This is one of four new measures being developed for cervical cancer – a topic with no existing measures.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Endorsed; MUC same as endorsed version: Yes; NQF endorsement review - 2015

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage.
Numerator: Patients of the Medicare prescribing provider whose daily morphine equivalent dose (MED) is greater than 90 mg for at least 90 consecutive days.
Denominator: Patients of the Medicare prescribing provider that are enrolled in a Part D Plan and who had two or more prescription claims totaling > 15 days supply for an opioid, on two separate occasions during the measurement year.
Exclusions: Denominator exclusions: • Patients receiving palliative or hospice treatment during the measurement period • Patients with cancer during the measurement period • Patients with critical limb ischemic pain during the measurement period • Patients with idiopathic pulmonary fibrosis during the measurement period • Patients with refractory angina during the measurement period • Patients with sickle cell disease during the measurement period
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims
Measure Type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Never submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an appropriate use/overuse and patient safety measure that is not duplicative of other measures in the clinician measure set. This MUC directly measures opioid over-prescribing. Data to determine the performance gap is needed.
- Impact on quality of care for patients:The CDC reports that drug overdoses are the leading cause of injury-related death in the United States and that the death rate from drug overdose has risen dramatically over the last decade. This increase is thought to be attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. There is substantial variation in opioid prescribing patterns across regions and providers, indicating a need for improvement in practices.
Does the measure address a program goal or objective? Yes. This is an appropriate use/overuse and patient safety measure applicable to Medicare Part D patients. There is no data on performance gap for this measure.
Is this a high-value measure? Yes. This is an appropriate use/overuse measure.
Does this measure fill a gap in the program measure set? Yes. Although there are three measures addressing opioid use in the clinician measure set, none specifically measure opioid overuse directly.
Measure development status: Early Development
Is the measure fully tested for the program's setting and level of analysis? No. Not yet tested
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This is a claims-based measure that poses minimal burden on providers; the measure is not duplicative of other measures in the clinician measure set.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never submitted

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 .

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

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #10 Dehydration Admission Rate • PQI #11 Bacterial Pneumonia Admission Rate • PQI #12 Urinary Tract Infection Admission Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status:
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Conditional support
Preliminary analysis summary
- Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. CONDITION: Successful testing for reliability and validity at the clinician level of analysis and submission of the composite to NQF.
Does the measure address a program goal or objective? . This composite measure supports improved individual and population health
Is this a high-value measure? Yes. This is a composite measure.
Does this measure fill a gap in the program measure set? Yes. MAP identified composite measures as a priority for MSSP.
Measure development status: The submitter notes that the measure is currently used in a CMS program (Physician VBPM), but the measure is undergoing substantial change
Is the measure currently in use? Yes. The measure is used in the VBPM.
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Composite measures are efficient because they provide more information from a single measure. The measure is aligned with other CMS reporting initiatives.
Is the measure NQF endorsed for the program's setting and level of analysis? No.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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.

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

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #1 Diabetes Short-Term Complications Admission Rate • PQI #3 Diabetes Long-Term Complications Admission Rate • PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate • PQI #7 Hypertension Admission Rate • PQI #8 Heart Failure Admission Rate • PQI #13 Angina Without Procedure Admission Rate • PQI #14 Uncontrolled Diabetes Admission Rate • PQI #15 Asthma in Younger Adults Admission Rate • PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area† or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status: This composite measure has not been submitted to NQF. However, 7 of the measures are NQF-endorsed as population-level measures for geographic areas:• PQI #1 Diabetes Short-Term Complications Admission Rate (NQF #272)• PQI #3 Diabetes Long-Term Complications Admission Rate (NQF #274)• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (NQF #275)• PQI #8 Heart Failure Admission Rate (NQF #277)• PQI #14 Uncontrolled Diabetes Admission Rate (NQF #638) • PQI #15 Asthma in Younger Adults Admission Rate (NQF #283)• PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate (NQF #285)In 2012 NQF removed endorsement of two component measures: PQI #7 Hypertension Admission Rate This measure only captures admissions with a primary diagnosis of hypertension. Many admissions for uncontrolled hypertension are for AMI or stroke rather than hypertension and are not captured in this measure. The Committee questioned interpretation of results. Also the documentation from the developer stated ” “Little evidence exists regarding the validity of this indicator,” and “some of the variance in age-sex adjusted rates does not reflect true differences in area performance.”. PQI #13 Angina Without Procedure Admission Rate This measure is looking for inappropriate admissions for angina - not over use of procedures. The measure implies that admission for angina as long as it is accompanied by a procedure is appropriate – the Committee thought this may encourage procedures. Also, coding has changed so that many patients are coded as coronary artery disease rather than angina which is a significant flaw in the measure.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the clinician level of analysis.
- Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs.
Does the measure address a program goal or objective? Yes. This nine component composite measure supports improved individual and population health. Two of the component measures are already in the MSSP measure set. One component - PQI #15 Asthma in Younger Adults Admission Rate – does not apply to Medicare age patients.
Is this a high-value measure? Yes. This is a composite measure.
Does this measure fill a gap in the program measure set? Yes. MAP identified composite measures as a priority for MSSP.
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? No. AHRQ : “We are developing risk adjustment approach and testing at an ACO level.”
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure might be applicable to ACOs if testing is successful at that level of analysis.
Is the measure currently in use? Yes. Measure currently used in a CMS program, but the measure is undergoing substantial change.
Does a review of its performance history raise any concerns? Yes. A risk-adjustment method for the ACO level of analysis is still being developed.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Two of the component measures are already in the MSSP program (heart failure and COPD readmissions ).
Is the measure NQF endorsed for the program's setting and level of analysis? No. This composite measure has not been submitted to NQF. However, 7 of the measures are NQF-endorsed as population-level measures for geographic areas:• PQI #1 Diabetes Short-Term Complications Admission Rate (NQF #272)• PQI #3 Diabetes Long-Term Complications Admission Rate (NQF #274)• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (NQF #275)• PQI #8 Heart Failure Admission Rate (NQF #277)• PQI #14 Uncontrolled Diabetes Admission Rate (NQF #638) • PQI #15 Asthma in Younger Adults Admission Rate (NQF #283)• PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate (NQF #285)In 2012 NQF removed endorsement of two component measures: PQI #7 Hypertension Admission Rate This measure only captures admissions with a primary diagnosis of hypertension. Many admissions for uncontrolled hypertension are for AMI or stroke rather than hypertension and are not captured in this measure. The Committee questioned interpretation of results. Also the documentation from the developer stated ” “Little evidence exists regarding the validity of this indicator,” and “some of the variance in age-sex adjusted rates does not reflect true differences in area performance.”. PQI #13 Angina Without Procedure Admission Rate This measure is looking for inappropriate admissions for angina - not over use of procedures. The measure implies that admission for angina as long as it is accompanied by a procedure is appropriate – the Committee thought this may encourage procedures. Also, coding has changed so that many patients are coded as coronary artery disease rather than angina which is a significant flaw in the measure.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

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

Measure Specifications

NQF Number (if applicable): 216
Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there
Numerator: Patients who died from cancer and spent fewer than three days in hospice
Denominator: Patients who died from cancer who were admitted to hospice
Exclusions: None
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Society of Clinical Oncology
Endorsement Status: Never Submitted
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Support
Preliminary analysis summary
- Contribution to program measure set:This measure addresses an important gap area in end-of-life care for reporting by oncologists, is fully-specified and tested, reflects patient-centered care, and addresses the important areas of care coordination and appropriate use. MAP has previously recommended expanding this measure beyond cancer patients.
- Impact on quality of care for patients:Approximately 500,000 patients will die of cancer in 2015. A 2014 study (Obermeyer Z, Makar M, et al) found that in Medicare fee-for-service beneficiaries with poor-prognosis cancer, a comparison of those receiving hospice care (60%) vs not (control) showed that hospice patients had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.
Does the measure address a program goal or objective? Yes. This measure addresses the priority domains of Communication and Care Coordination; Appropriate Use
Is this a high-value measure? Yes. Promotes communication, care coordination, and appropriate use of services; will lead to more patient-centered care and lower healthcare costs.
Does this measure fill a gap in the program measure set? Yes. End-of-life care is an identified gap in the clinician measure set; currently, there are no other measures in the MIPS or MSSP programs that promote appropriate end-of-life care. Fills gaps in the following MAP Measure Families: Affordability; Care Coordination; and Hospice
Measure development status: This measure is NQF-endorsed (NQF#0216); full specifications and testing information are provided.
Is the measure fully tested for the program's setting and level of analysis? Yes. During a 2012 NQF endorsement maintenance review, the developer provided results of testing for reliability and validity at the data element level, assessing the accuracy of claims data compared to data from derived from medical record review.
Is the measure currently in use? Yes. The American Society of Clinical Oncology (ASCO)´s Quality Oncology Practice Initiative (QOPI) uses a modified version of this measure (hospice enrollment more than 7 days before death) and reports de-identified practice variation for QOPI participants.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This measure is also under consideration for the Physician Compare and Medicare Shared Savings (MSSP) programs. The MUC responds to two highly prioritized measurement opportunities identified in MAP’s 2012-2013 report Performance Measurement Coordination Strategy for Hospice and Palliative Care:Timeliness/responsiveness of care is vital to providing optimal hospice care as it prevents unnecessary ED visits and hospital admissions and readmissions. Given that the average length of stay for hospice care is relatively brief, timely care is essential to support patients and caregivers, enhance autonomy, prevent unwanted admissions, and improve experience of care. Further, a time factor should be incorporated into other measure concepts such as assessments and care planning. Avoiding unwanted treatments, when measured, serves as a proxy for appropriate levels of communication and care planning in hospice programs. Unwanted treatments also include unnecessary hospital/ED admissions and readmissions.
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

Summary of NQF Endorsement Review

Year of Most Recent Endorsement Review: 2011
Project for Most Recent Endorsement Review: Cancer Endorsement Maintenance 2011
Review for Importance: The measure meets the Importance criteria.(1a. High Impact; 1b. Performance Gap; 1c. Evidence)1a. Impact: H-14; M-3; L-0; I-0; 1b. Performance Gap: H-13; M-3; L-1; I-0; 1c. Evidence: Y-16, N-1, I-0Rationale:• It is well documented that short lengths of stay in hospice compromises patients' quality of care and that there is a substantial portion of hospice patients that are referred within 1-3 days of death.• The measure affects a large number of patients and is high impact.• Many cancer patients die in a hospital receiving futile care until the end. Referring patients to hospice, when appropriate, addresses patient preferences, improves quality of care, and reduces health care costs.• The Steering Committee noted that poor performance on this measure would indicate that providers are failing to have direct conversations with their patients about the futility of further treatment and the benefits of hospice care.• The committee felt the measure developer provided good evidence to support that the concept that hospice referral would mean increased quality of care.
Review for Scientific Acceptability: The measure meets the Scientific Acceptability criteria.(2a. Reliability – precise specifications, testing; 2b. Validity – testing, threats to validity)2a. Reliability: H-14; M-3; L-1; I-0; 2b. Validity: H-13; M-4; L-0; I-0Rationale:• Steering Committee members questioned why three days was selected as the numerator. The developer noted that three days is the minimum lowest bar; seven days may be a better indicator of quality of care. Also, data was more easily obtained with the three day threshold than the seven day threshold.• The measure is well specified.• The reliability testing for the measure is appropriate and demonstrates the reliability of the measure.• Face validity of the measure was demonstrated.
Review for Feasibility: H-12; M-5; L-0; I-0(4a. Clinical data generated during care process; 4b. Electronic data; 4c.Susceptibility to inaccuracies/ unintended consequences identified 4d. Data collection strategy can be implemented)Rationale:• The measure is reported using claims data and is feasible to implement.• Steering Committee members noted that this measure in conjunction with measure #0215 would prevent providers from not sending patients to hospice because of the fear that the patient would die in the next 3 days and prevents providers from making patient care decisions about sending patients to hospice based on measure performance.
Review for Usability: H-11; M-6; L-0; I-0(Meaningful, understandable, and useful to the intended audiences for 3a. Public Reporting and 3b. Quality Improvement)Rationale:• The measure is usable for public reporting, as it captures the use of hospice for appropriate patients.• The measure is useful for QI, particularly when comparing facilities with similar patient populations to see if there are irregularities in achieving this measure.• The measure is in use through ASCO’s QOPI program.
Endorsement Public Comments: Commenters indicated support for the measure.
Endorsement Committee Recommendation: Y-17; N-0Rationale: The Steering Committee found that the measure affects a large patient population and will help identify when facilities are providing overly aggressive, futile care to patients rather than referring them to hospice.

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

Measure Specifications

NQF Number (if applicable):
Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report.
Numerator: Number of percutaneous image-guided biopsy procedures performed associated with a specimen sample considered adequate for pathological analysis.
Denominator: Number of percutaneous image-guided biopsies performed
Exclusions: Repeat biopsy procedures performed at the same site following an initial inadequate sample
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This intermediate outcome measure assesses imaging specialists for a wide variety of patient conditions. The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. A consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes.
- Impact on quality of care for patients:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies
Does the measure address a program goal or objective? Yes. This intermediate outcome measure for interventional radiologists assesses the success of obtaining adequate samples during biopsies..
Is this a high-value measure? Yes. Intermediate outcome measure.
Does this measure fill a gap in the program measure set? Yes. Applicable to a wide variety of patients.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Group Practice environment, Academic Medical Center, Community Hospital
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This measure is applicable to a variety of clinicians and patients
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who underwent vaginal hysterectomy
Numerator: Total number of patients undergoing vaginal hysterectomy (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554)
Denominator: Total number of patients undergoing hysterectomy of any type. (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554, 58544, 58570, 58571, 58572, 58573, 58541, 58542, 58543, 58150, 58152, 58180)
Exclusions: Patients with a preoperative diagnosis of cancer (applies to both numerator and denominator, ICD-10 codes) Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Intermediate Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:The measure provides an intermediate outcome addressing appropriate use and patient safety for a commonly performed surgical procedure for gynecologists. It is unclear what level of performance is desirable and case-mix adjustment may be necessary to make fair comparisons among gynecologists.
- Impact on quality of care for patients:Hysterectomy is one of the most frequently performed surgical procedures in the US. ACOG concludes that “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications.” 2010 data indicate that hysterectomies are performed vaginally (19%), abdominally (56%), or with laparoscopic (25%) or robotic assistance. ACOG notes that “abdominal hysterectomy is also an important surgical procedure, especially when the vaginal or laparoscopic approach is not appropriate to manage the patient's clinical situation or when facilities cannot support a specific procedure.” While encouraging vaginal hysterectomy as the safer procedure, it is unclear how many patients are not candidates for a vaginal hysterectomy and what the target for this measure should be or whether the patient clinical factors are equally distributed among gynecologists.
Does the measure address a program goal or objective? Yes. The measure is an intermediate outcome addressing appropriate use and patient safety for a commonly performed surgical procedure for gynecologists.
Is this a high-value measure? Yes. This is an intermediate outcome measures with appropriate use characteristics.
Does this measure fill a gap in the program measure set? Yes. There are few measures for gynecologic surgery in the current set.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: group/individual practices
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented endoscopy
Numerator: Patients with diagnosis of cirrhosis that have documented endoscopy in the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Currently taking non-selective beta – blocker, life expectancy of < 1 year, patient declines
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Do not encourage further consideration
Preliminary analysis summary
- Contribution to program measure set: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.
- Impact on quality of care for patients: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.
Does the measure address a program goal or objective? Yes. This measure addresses a topic area with few measures.
Is this a high-value measure? No. Screening endoscopy is recommended by AASLD in patients with cirrhosis (Level 1 recommendations) but it is based on Level C evidence – consensus only.
Does this measure fill a gap in the program measure set? No.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? No information on testing
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
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
Numerator: Patients with a diagnosis of Chronic Hepatitis B that have had a documented abdominal US, CT Scan, or MRI in the measurement period
Denominator: All patients with diagnosis of Chronic Hepatitis B
Exclusions: Exclusions: none Exceptions: All patients with known diagnosis of hepatoma, life expectancy less than 1 year, or patient declined screening during the measurement.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Do not encourage further consideration
Preliminary analysis summary
- Contribution to program measure set: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. The registry is not specified.
- Impact on quality of care for patients:The current evidence indicates that the benefit to patients is uncertain. The costs of screening without evidence of a benefit are not justified.
Does the measure address a program goal or objective? Yes . 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.
Is this a high-value measure? No. A systematic review of Screening for Hepatocellular Carcinoma in Chronic Liver Disease (Aug 2014) 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.”
Does this measure fill a gap in the program measure set? Yes. This would compliment PQRS# 401 Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis.
Measure development status: Field Testing – level of testing not indicated
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively
Numerator: Patients who achieved an improvement in MRD postoperatively compared to their preoperative level
Denominator: Patients aged 18 years or older with a diagnosis of acquired involutional ptosis who underwent a surgical procedure for the condition
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an outcome measure for oculoplastic surgeons – a subspecialty with few or no measures. Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes. As many surgeries are performed primarily for cosmetic reasons a patient-reported outcome measure is also needed.
- Impact on quality of care for patients:Ptosis is a lowering of the eyelid to below its normal position. The distance between the corneal light reflex and the upper eyelid margin is termed the upper marginal reflex distance. The official definition of ptosis is an upper marginal reflex distance below 2 mm or an asymmetry of more than 2 mm between the eyes. Ptosis has many causes and is a presenting symptom in both emergency and outpatient settings. In many cases, ptosis improves with time, however, in the absence of improvement surgery may be considered. Data on current performance to determine the opportunity for improvement could not be identified.
Does the measure address a program goal or objective? Yes. This is an outcome measure for oculoplastic surgeons.
Is this a high-value measure? Yes. This is a surgical outcome measure.
Does this measure fill a gap in the program measure set? Yes. Oculoplastic surgeons have few or no measures in the set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure is being tested in ambulatory/office-based care. 11/30/2015: The measures submitted by the America Academy of Ophthalmology on the MUC list are still undergoing testing, we would expect this to be completed by the Spring of 2016. The measures are currently specified for registry based reporting and electronic capture from EHRs (eCQMs) for use in the IRIS Registry. The measures are included in our Qualified Clinical Data Registry (QCDR) for PQRS reporting in 2015.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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)

Measure Specifications

NQF Number (if applicable):
Description: Uterine cancer patients with adequate surgical staging performed with a grade 3 tumor and deep uterine wall invasion.
Numerator: Number of women with a grade 3 endometrial cancer identified with greater than 50% myometrial invasion who have a surgical staging procedure with lymph node removals
Denominator: Total number of women with a grade 3 endometrial cancer ( ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 ) undergoing surgery who are found to have greater than 50% myometrial invasion
Exclusions: Women with poor performance status or medical co-morbidities in which increased surgical time or staging procedures place patient at significant risk or women identified preoperatively with advanced stage disease or treated with preoperative chemotherapy and/or radiation if not a surgical candidate Exceptions: Women with poor performance status or medical co-morbidities in which increased surgical time or staging procedures place patient at significant risk or women identified preoperatively with advanced stage disease or treated with preoperative chemotherapy and/or radiation if not a surgical candidate
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This appropriateness measure for surgical care of patients with advanced uterine cancer adds a measure for a topic area not currently addressed in the measure set. Data on current performance is important to understand the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:Patient who do not receive a lymph node dissection during surgery have a poorer outcomes. Minimizing the number of women who receive sub-standard care will benefit women with uterine cancer.
Does the measure address a program goal or objective? Yes. This is an appropriateness measure for surgical care of patients with advanced uterine cancer for GYN and GYN ONC specialists that have few measures.
Is this a high-value measure? Yes. This is an appropriateness measure for surgical and cancer care.
Does this measure fill a gap in the program measure set? Yes. GYN and GYN ONC specialists have few measures.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Patients with diagnosis of Crohn’s disease who have had a colonoscopy in the measurement period or 1 year prior to measurement year
Denominator: All patients with diagnosis of colonic Crohn’s Disease
Exclusions: Exclusions: none Exceptions: Diagnosis of colonic Crohn’s Disease for < 10 years, isolated small bowel Crohn’s disease, life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:There are no measures that focus on Crohn’s Disease in the current measures set and this measure would complement other colonoscopy measures. Data on current performance would provide a better understanding of the gap in care. Registry not specified.
- Impact on quality of care for patients: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. Early detection of cancer can improve long term survival. ASGE guidelines recommend that patients with Crohn’s Disease for more than 10 years should have a surveillance colonoscopy every 1-2 years
Does the measure address a program goal or objective? Yes. This is a population health/prevention measure for patients at higher risk for colon cancer.
Is this a high-value measure? Yes. This is a population health/prevention measure.
Does this measure fill a gap in the program measure set? Yes. There are no measures that focus on Crohn’s Disease in the current measures set and this measure would complement other colonoscopy measures.
Measure development status: Field Testing – level of testing unknown
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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)

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of Ulcerative Colitis for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period.
Numerator: Patients with diagnosis of Ulcerative Colitis who have had a colonoscopy in the measurement period or 1 year prior to measurement year
Denominator: All patients with diagnosis of Ulcerative Colitis
Exclusions: Exclusions: none Exceptions: Diagnosis of colonic Ulcerative Colitis for < 10 years, life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:There are no measures that focus on Ulcerative Colitis in the current measures list and this measure would compliment other colonoscopy measures. The registry is not specified. Data on current performance would provide a better understanding of the gap in care.
- Impact on quality of care for patients:American College of Gastroenterology guidelines state “after 8 – 10 years of colitis, annual or biannual surveillance colonoscopywith multiple biopsies at regular intervals should be performed (Evidence B). Aft er 10 years of universaldisease, the cancer risk has been widely reported in the range of 0.5 – 1 % per year. However, a recent nation-wide population-based analysis from the Netherlands found that 20% of all UC-related cancers were detected before 8 years of diseasehad elapsed.
Does the measure address a program goal or objective? Yes. This screening measure addresses a new condition – ulcerative colitis – and is related to several measures: NQF #0659 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use; NQF #0658 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients; and PQRS# 343 Screening Colonoscopy Adenoma Detection Rate Measure
Is this a high-value measure? Yes. Population health and prevention
Does this measure fill a gap in the program measure set? Yes. There are no measures that focus on Ulcerative Colitis in the current measures list and this measure would compliment other colonoscopy measures.
Measure development status: Field Testing – level of testing not indicated
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period
Numerator: Patients with diagnosis of Barrett's Esophagus who have had an upper endoscopy during the measurement period or the four years prior to the measurement period
Denominator: All patients with diagnosis of Barrett’s Esophagus
Exclusions: Exclusions: None Exceptions: Denominator: Life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Though other measure addressing GI endoscopy are in the clinician measure set, none address Barrett’s esophagus. Data on current performance would provide a better understanding of the opportunity for improvement.
- Impact on quality of care for patients:Barrett’s esophagus is a serious complication occurring in about 10-15% of patients with GERD (reflux).Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's esophagus although less than 1% of patients develop cancer. Nov 2015 guidelinees from American College of Gastroenterology recommend endoscopic surveillance every 3-5 years (strong recommendation, moderate evidence).
Does the measure address a program goal or objective? Yes. This measure addresses a new topic area and provides an additional measure for gastroenterologists.
Is this a high-value measure? Yes. This is a population health/prevention measure.
Does this measure fill a gap in the program measure set? Yes. Though other measure addressing GI endoscopy are in the clinician measure set, none address Barrett’s esophagus.
Measure development status: Field Testing; level of testing unknown
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? No. N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? .
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

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

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852).
Numerator: Number of patients that were asked about abnormal uterine or postmenopausal bleeding, or those that had an ultrasound and/or endometrial sampling of any kind. These would be identified by chart review or entry into the PFD Registry.
Denominator: CPT code 57120- colpocleisis
Exclusions: Prior hysterectomy Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is a patient safety measure for appropriate work-up prior to surgery for elderly females. Applicable to gynecologists and female pelvic medicine and reconstructive surgery (FPMRS) specialists.
- Impact on quality of care for patients:The lifetime risk of having surgery for prolapse or incontinence by age 80-85 is 11-19% and projected to increase. Obliterative surgery (colpocleisis) closes the vagina to keep the organs within the pelvis and is an alternative for patients who cannot tolerate extensive surgery and no longer desire preservation of sexual function. Before surgery, work-up should eliminate any co-existing malignant condition before access to the organs is closed off. Data could not be found on the number of these surgeries performed each year.
Does the measure address a program goal or objective? Yes. This is a patient safety measure for appropriate work-up prior to surgery for elderly females. Applicable to gynecologists and female pelvic medicine and reconstructive surgery (FPMRS) specialists
Is this a high-value measure? Yes. A patient safety measure.
Does this measure fill a gap in the program measure set? Yes. There are few measures for gynecologists or FPMRS specialists.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: group/individual practices
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy
Numerator: Number of patients who receive brachytherapy as part of their treatment for cervical cancer (Cervical cancer ICD-10 dx code C53.9) CPT 77785, 77786, 77787, 77761, 77762, 77763
Denominator: All patients undergoing primary radiation for cervical cancer (cervical cancer diagnosis code C53.9) with curative intent: 77385, 77386, 77402, 77407, 77412
Exclusions: Patients receiving palliative radiation, patients with stage IVB Exceptions: Patients on clinical trial
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is a process measure closely linked to clinical outcomes (patient survival) with a demonstrated quality problem/opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:In the US there were 12,900 cases and 4100 deaths from cervical cancer this year. Radiation therapy is included in treatment protocols for all but the earliest stage of cancer. Brachytherapy is internal radiation placed in and near the cervix with minimal radiation exposure to other areas. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. According to the American Brachytherapy Society Cervical Cancer Brachytherapy Task Group “The radiation dose delivered by brachytherapy is critical in curing patients of cervical cancer and has been the standard of treatment for over 100 years.” 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. Improvement in use of brachytherapy will improve survival in women with cervical cancer.
Does the measure address a program goal or objective? Yes. This is a measure for GYN ONC and Radiation ONC specialists who have few measures.
Is this a high-value measure? Yes. This process measure is strongly linked to outcomes, i.e., longer survival in women with cervical cancer.
Does this measure fill a gap in the program measure set? Yes. There are few measures for cervical cancer treatment in the current set.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy.
Numerator: Numerator is the number of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. ICD9 codes 180.0-180.9, CPT codes 96409, 96411, 96417.
Denominator: Number of patients with stage IIB-IV cervical cancer who receive primary radiation therapy. ICD9 codes 180.0-180.9, CPT codes 57155, 57156, 77261-77299, 77300-77399, 77401-77421, 77785, 77786, 77787, 77799.
Exclusions: Patients who have a medical contraindication to receipt of platinum-based chemotherapy should receive an alternative chemotherapy agent that has been demonstrated to have clinical benefit in patients with cervical cancer. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This measure for treatment of advanced cervical cancer is one of four new measures for cervical cancer management – an area that does not have current measures. Data on current performance is needed to understand the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
- Impact on quality of care for patients:A 2010 Cochrane review found that women who had chemoradiotherapy for cervical cancer were likely to live for longer than women who had just radiotherapy. Although this measure promotes the best recommended care and should improve the outcomes for women with cervical cancer, it is unclear how many patients are not receiving appropriate chemoradiation therapy. The impact will be limited if patients are already receiving this standard of care.
Does the measure address a program goal or objective? Yes. There are no current measures for cervical cancer management.
Is this a high-value measure? Yes. This is a new topic area for the set and provides a measure for GYN oncologists who have few measures.
Does this measure fill a gap in the program measure set? Yes. Appropriate use and measures for GYN Oncologists
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in individual and group practices. Reliability and valildity testing expected to be completed in 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Most effective therapy for patient outcomes
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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)

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings.
Numerator: Number of pathologically-proven primary SCCis or SCC-KA lesions on the trunk (chest, back, abdomen) that are 1 cm or smaller in immunocompetent patients treated by the provider utilizing Mohs surgery.
Denominator: All pathologically-proven primary SCCis or SCC-KA lesions on the trunk (chest, back, abdomen) that are 1 cm or smaller in immunocompetent patients treated by the provider within the reporting period.
Exclusions: Exclusions: • Patients with a genetic syndrome that increases their risk for skin cancer. • Tumors in areas of previous radiation therapy. • Tumors that have pathologically documented areas of dermal invasion, or dermal invasion is found on any stage if Mohs surgery is performed. • Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample. • Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is another appropriate use measure for dermatology. 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 cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
- Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique.
Does the measure address a program goal or objective? Yes. MIPS priority domain: Appropriate use
Is this a high-value measure? Yes. Appropriate use/overuse
Does this measure fill a gap in the program measure set? Yes. There are few appropriate use measures in the clinician measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Mohs surgery is commonly performed in outpatient setting. Level of Analysis Tested: Individual practice, group practice, University hospital setting (Academic) Setting of Measure Testing: Office- Based Care, Hospital Setting (Academic, Dermatology). The measure is in testing now with results expected in Summer - Fall 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. As a high value measure that should have an important impact on care.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings.
Numerator: Number of pathologically-proven primary superficial BCC’s treated by the provider utilizing Mohs surgery.
Denominator: All pathologically-proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) on immune-competent patients treated by the provider within the reporting period.
Exclusions: Exclusions: • Tumors that have a pathologically documented mixed histology including a more aggressive histologic subtype, or a more aggressive tumor is found on any stage if Mohs surgery is performed. • Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample. • Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is an appropriate use measure for dermatology. 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 cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
- Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique.
Does the measure address a program goal or objective? Yes. MIPS priority domain: Appropriate use
Is this a high-value measure? Yes. The is an appropriate use/overuse measure.
Does this measure fill a gap in the program measure set? Yes. More appropriate use measures are need in the clinician measure set.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Mohs surgery is commonly performed in outpatient setting. Level of Analysis Tested: Individual practice, group practice, University hospital setting (Academic) Setting of Measure Testing: Office- Based Care, Hospital Setting (Academic, Dermatology). The measure is in testing now with results expected in Summer - Fall 2016.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals.
Numerator: Number of patients receiving sun protection education and a full skin exam once within the reporting period (1 year) by the provider or documentation of either a referral to or completion of these preventative activities by a dermatologist.
Denominator: All organ transplant recipients seen by provider in an outpatient setting within the reporting period.
Exclusions: Exclusions: Documented refusal by patient to schedule follow-up annual screens after documented appropriate counseling on risk for skin cancer.
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This is a process measure assessing whether screening and education activities have been performed. This measure addresses population health and prevention. The measure adds to the measures specific to dermatology, and addresses the new area of organ transplant recipients. No data is provided to understand current performance or gap in care. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
- Impact on quality of care for patients:29,532 people received organ transplants in 2014. Due to the effects of immunosuppressive medications and other risk factors, these recipients are at significantly higher risk for skin cancer. If patients are already receiving screening and education, the impact on patients will be limited.
Does the measure address a program goal or objective? Yes. This measure addresses population health and prevention. No information on current performance or gap was provided.
Is this a high-value measure? No. This is a process measure assessing whether screening and education activities have been performed. Screening measure should include follow-up activities and education measures should include the patient’s assessment of the effectiveness of the education.
Does this measure fill a gap in the program measure set? Yes. There are currently only seven dermatology-specific measures in the clinician measure set. This measure adds to the relatively limited set of measures addressing skin conditions.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis Tested: Individual practice, group practice, University hospital setting (Academic) Setting of Measure Testing: Office- Based Care, Hospital Setting (Academic, Dermatology). The measure is in testing now with results expected in Summer - Fall 2016.
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This measure addresses a new topic area not currently in the clinician measure set.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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).

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)

Measure Specifications

NQF Number (if applicable):
Description: Documentation of ISD prior to procedure
Numerator: Percentage of patients who have documented ISD prior to procedure
Denominator: All patients who underwent the procedure CPT code 51715 and ICD-9 code 599.82
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:Documentation of indications for a procedure is standard of care. According to the submitter the literature indicates the criteria for ISD are imprecise (“ISD criteria usually: not mobile urethra, VLPP less than 60mm H2O or MUCP less than 20mm H2O.”). Specifications should explicitly state which criteria must be included to establish ISD. An appropriate use of bulking agent procedure measure might be more meaningful and useful.
- Impact on quality of care for patients:Patients will benefit if documentation of ISD more effectively selects appropriate patients to undergo the procedure. Data on current performance would provide a better understanding of the opportunity for improvement.
Does the measure address a program goal or objective? Yes. This measure attempts to address appropriate patient selection for use of bulking agents for urinary incontinence. This is not an outcome measure.
Is this a high-value measure? No. This is a documentation measure, not an outcome measure.
Does this measure fill a gap in the program measure set? No. An appropriateness measure would better fill a gap.
Measure development status: Early Development, Field Testing
Is the measure fully tested for the program's setting and level of analysis? No. Level of Analysis Tested: group/individual practices
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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.

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

Measure Specifications

NQF Number (if applicable): 326
Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Numerator: Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Denominator: All patients aged 65 years and older.
Exclusions: N/A
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Other
Measure Type: Process
Steward: National Committee for Quality Assurance
Endorsement Status: NQF measure #326 was endorsed in 2012 and was tested in 220 Medicare patients using paper and electronic medical records in four practice sites. Inter-rater reliability was high at all four sites.
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Support
Preliminary analysis summary
- Contribution to program measure set:This measure is aligned with PQRS/MIPS, addresses an important need for patients and caregivers and is a cross-cutting communication and care coordination measure applicable to all Medicare patients..
- Impact on quality of care for patients:In 2010, there were 40.3 million people aged 65 and older, a 13% share of the US population, that is projected to reach 20.9% by 2050. As people age, consideration should be given to their treatment wishes in the event that they lose the ability to manage their care. A large discrepancy exists between the wishes of dying patients and their actual end-of-life care. Advance Care Plan is recommended as a strategy to improve compliance with patient wishes, and thereby ensure appropriate use of health care resources at the end of life.
Does the measure address a program goal or objective? Yes. Yes, the measure addresses Communication and Care Coordination and is needed for all Medicare patients and their families.
Is this a high-value measure? Yes. This patient engagement measure is addresses a patient/caregiver priority area.
Does this measure fill a gap in the program measure set? Yes. The measure addresses patient and family centered care and shared decision-making
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? No. Setting tested: Ambulatory/office-based care Level of analysis: Individual clinicians and Clinicians in Group/Practice
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. As with other clinician-level measures used in PQRS and MSSP, the aggregate results of all clinicians may roll up to an ACO level result.
Is the measure currently in use? Yes. PQRS
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Currently a part of the PQRS program reported by claims, registry and measure groups (Chronic Kidney Disease, Heart Failure, HIV/AIDS, Parkinson's Disease, COPD, Dementia).
Is the measure NQF endorsed for the program's setting and level of analysis? Yes. NQF measure #326 was endorsed in 2012 and was tested in 220 Medicare patients using paper and electronic medical records in four practice sites. Inter-rater reliability was high at all four sites.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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.

Summary of NQF Endorsement Review

Year of Most Recent Endorsement Review: 2012
Project for Most Recent Endorsement Review: Care Coordination Endorsement Maintenance 2012: Phases 1 and 2
Review for Importance: based on decision logic): Yes(1a. High Impact: 1b. Performance Gap 1c. Evidence)1a. Impact: H-23; M-3; L-0; I-0 1b. Performance Gap: H-20; M-4; L-0; I-2 1c. Evidence: Y-15; N-4; I-7Rationale: The Committee expressed strong support of the importance of advanced care planning for this population. There was overall agreement on both a gap in performance as well as an overall low performance for this measure, although there was a desire by some members of the Committee to see performance statistics for various population subgroups (e.g., underserved groups, cognitively impaired, etc.). Committee members also suggested that while there is strong evidence for the value of advanced care planning overall, there is less evidence linking advanced care planning to desired outcomes such as improved quality of life or potential cost savings.
Review for Scientific Acceptability: based on decision logic): Yes(2a. Reliability – precise specifications, testing; 2b. Validity – testing, threats to validity)2a. Reliability: H-6; M-11; L-5; I-4 2b. Validity: H-2; M-11; L-7; I-6Rationale: There was considerable difference of opinion between Committee members regarding the reliability and validity of the measure (note that there was a tie for validity). Much of the concern with this measure was related to how the measure is specified. Committee members were confused about what is actually being measured (i.e., that a “conversation” occurred, that various components of an advanced care plan, such as an advanced directive, durable power of attorney, etc.—have been documented, or some combination). They were also concerned about the time frame of the measure, since it seems to be measuring, on an annual basis, whether or not an advanced care plan is documented in the medical record—but is not measuring whether the plan has been updated, or at least discussed, at least annually. While the developer clarified that this measure holds the physician accountable for the documentation, Committee members maintained it is often other providers (e.g., nurse, social worker) who often have advanced care conversations with patients. Additionally, Committee members were concerned that advanced care planning conversations are actually occurring, but for some reason, they are not being captured with this measure through the use of CPT-II codes. There was also considerable discussion about the testing of the measure, and although the developer described inter-rater reliability testing done based on manual record abstraction, some Committee members were not convinced that adequate testing had been done to assure that reporting of a CPT-II code does in fact reflect actual documentation of advanced care planning in the medical record.
Review for Feasibility: H-2; M-12; L-10; I-2(4a. Clinical data generated during care delivery; 4b. Electronic sources; 4c.Susceptibility to inaccuracies/ unintended consequences identified 4d. Data collection strategy can be implemented)Rationale: There was disagreement among Committee members about the feasibility of this measure due to uncertainties about the specificity of the measure, it’s reliance on the use of CPT-II codes, the relatively low reporting rate of the measure in the 2008 PQRI, and reservations about capturing appropriate data elements in electronic systems.
Review for Usability: H-4; M-14; L-8; I-0(Meaningful, understandable, and useful to the intended audiences for 3a. Public Reporting/Accountability and 3b. Quality Improvement)Rationale: Developers noted that the reporting rate submitted by the developer was based on all physicians, and that specialists or those with few patients age 65 years or older in their practice likely would not choose to report on this measure.
Endorsement Public Comments: Comments included:
- Commenters were concerned that this measure is a “check-box” measure and will not have an effect on quality, outcomes, or cost.
- Suggested areas for improvement included specifying required elements for the advance care plan, including a broader array of providers who could be held accountable for, and empowered to, create and document such a plan in the patient record, measuring whether the advance care plan was followed and updated accordingly, and identifying and including patient preferences in the advance care plan
- The measure represents a reasonable starting point but more development is needed in this area
Developer Response:
- NCQA and AMA/PCPI agrees this measure is limited in the information it captures. However, it is important to note that even as a limited measure, performance (50% in 2010) demonstrates an important quality gap that needs to be addressed. There are many tools which are available to physicians to guide the advanced care planning discussion with patients and outline the important elements which should be documented. The measure specification provided by NCQA and AMA/PCPI on the AMA website lists several elements which may be important to include or discuss in the advanced care planning process. However, NCQA and AMA/PCPI believes the specific elements of an advanced care plan are best decided on by the provider and patient.
- We appreciate this comment and wish to clarify that this measure does not limit advanced care planning documentation to a physician.
- Regarding the comment that more development is needed in this area: NCQA appreciates the suggestion and encourages the development of more measures in this area.
Steering Committee Response: In their discussion of these comments, the Committee remained somewhat divided on this measure. One member reiterated concerns about the validity of the measure, and agreed with the commenters that it is a check-the-box measure. However, other members stated that while the measure, as specified, may not go far enough, it is better than nothing. The Committee agreed to re-evaluate the measure after further reviewing the measure specifications, notes from the in-person meeting, and comments. Upon re-evaluation, the Committee again decided to recommend the measure.Vote Following Consideration of Public and Member Comments:1. Importance to Measure and Report (based on decision logic): Yes1a. Impact: H-12; M-4; L-2; I-0 1b. Performance Gap: H-11; M-7; L-0; I-0 1c. Evidence: Y-12; N-1; I-52. Scientific Acceptability of Measure Properties (based on decision logic): Yes2a. Reliability: H-0; M-13; L-2; I-3 2b. Validity: H-0; M-11; L-4; I-3Usability: H-5; M-9; L-2; I-2Feasibility: H-3; M-11; L-2; I-2Steering Committee Recommendation on Overall Suitability for Endorsement: Y-13; N-5 Rationale: While the Committee acknowledged weaknesses with the measure, they again noted the importance of the topic and encouraged developers to continue to refine the measure.
Endorsement Committee Recommendation: Y-18; N-8Rationale: Committee members recommended this measure as suitable for endorsement at this time because of the importance of the topic; however, the Committee strongly expressed their desire for better measures of advanced care planning. CSAC Review (July 12, 2012) Decision: Approved for continued endorsement
The CSAC, like the Steering Committee, was divided on the usefulness of this measure. Some members reiterated concerns that the measure, as currently specified, is a “check-the-box” measure that will not impact patient outcomes while others considered the measure “a starting point” that is necessary because currently the creation/discussion of an advance care plan is still far from standard practice.,. Some CSAC members voiced the idea that not recommending the measure might drive other developers to create a better, more meaningful measure; others however, voiced the their belief that continued endorsement would at least signal to providers that creation of an advance care plan is an expected component of good quality care. Ultimately, the CSAC voted 9 to 5 (with one abstention), to support the Steering Committee’s recommendation for endorsement, noting that the measure should be considered as one step on the way to a more progressive measure that incorporates such aspects as patient and family understanding.
Board Review (August 8, 2012)Decision: Ratified for continued endorsement

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

Measure Specifications

NQF Number (if applicable): 101
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.
Numerator: This measure has three rates. The numerators for the three rates are as follows: A) Screening for Future Fall Risk: Patients who were screened for future fall* risk** at last once within 12 months B) Falls: Risk Assessment: Patients who had a risk assessment*** for falls completed within 12 months C) Plan of Care for Falls: Patients with a plan of care**** for falls documented within 12 months. *A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force. **Risk of future falls is defined as having had had 2 or more falls in the past year or any fall with injury in the past year. ***Risk assessment is comprised of balance/gait assessment AND one or more of the following assessments: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. ****Plan of care must include consideration of vitamin D supplementation AND balance, strength and gait training.
Denominator: A) Screening for Future Fall Risk: All patients aged 65 years and older. B & C) Risk Assessment for Falls & Plan of Care for Falls: All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).
Exclusions: Patients who have documentation of medical reason(s) for not screening for future fall risk, undergoing a risk-assessment or having a plan of care (e.g., patient is not ambulatory) are considered exclusions to this measure.
HHS NQS Priority: Making Care Safer
HHS Data Source: Paper medical record
Measure Type: Process
Steward: National Committee for Quality Assurance
Endorsement Status: Previously endorsed in 2007 and 2012, NQF #101 has been recommended for continued endorsement by the Patient Safety Standing Committee in 2015.
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Support
Preliminary analysis summary
- Contribution to program measure set:Prevention of falls is a cross-cutting, patient safety measure applicable to all Medicare patients. This NQF-endorsed measure is aligned with PQRS.
- Impact on quality of care for patients:According to the CDC, one out of three adults aged 65 or older falls each year, but less than half talk to their healthcare providers about it, suggesting an opportunity for improvement that would be addressed by this measure. The CDC reports that falls are the leading cause of both fatal and nonfatal injuries in older adults, and that in 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion.
Does the measure address a program goal or objective? Yes. This measure is related to patient safety, one of the primary domains for measures in the Medicare Shared Savings Program (MSSP), and is aligned with the PQRS program
Is this a high-value measure? Yes. This is a process measure that addresses an important and high-impact area in prevention of falls in older adults; there is fair-to-good evidence linking the processes in this measure to outcomes
Does this measure fill a gap in the program measure set? Yes. Currently, there are no other falls-related measures in the MSSP
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Setting tested: Individual clinician; group/practice Level of analysis: Individual clinician; group/practice
Is the measure currently in use? Yes. The measure is in the PQRS and Meaningful Use prgram measure sets.
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Both measures (Falls: risk assessment and Falls: plan of care are in PQRS and the EHR Incentive Program. Part A (risk assessment) of the measure in the MSSP and it is already reported via the GPRO Web Interface.
Is the measure NQF endorsed for the program's setting and level of analysis? Yes. Previously endorsed in 2007 and 2012, NQF #101 has been recommended for continued endorsement by the Patient Safety Standing Committee in 2015.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

Summary of NQF Endorsement Review

Year of Most Recent Endorsement Review: 2015
Project for Most Recent Endorsement Review: Patient Safety 2015 (Draft report available as of 9/17/2015)
Review for Importance: The measure meets the Importance criteria (1a. Evidence, 1b. Performance Gap) 1a. Evidence: 13-H; 8-M; 1-L; 0-I; 1b. Performance Gap: 15-H; 6-M; 2-L; 0-I; Rationale: Evidence supported by the USPSTF, the American Geriatric Society, the British Geriatric Society, and the American Organization of Orthopedic Surgeons. However, there is more evidence on plans of care than assessments of falls being links to lower fall rates. · The measure focuses on people who have fallen more than once or who have had an injurious fall. · The reported rates demonstrate room for improvement as well as disparities in performance.
Review for Scientific Acceptability: The measure meets the Scientific Acceptability criteria (2a. Reliability - precise specifications, testing; 2b. Validity - testing, threats to validity) 2a. Reliability: 11-H; 11-M; 1-L; 0-I 2b. Validity: 8-H; 14-M; 1-L; 0-I Rationale: · This is a long-endorsed measure that is currently in use and the Committee had no concerns regarding the reliability or validity. After the original endorsement, additional reliability testing was performed in 2013 at the data element level; the measure has undergone face validity testing. · Reliability testing was done at the data element level. The denominators across all three rates had a 100% rate. The numerators had kappa scores above 0.90. · For a systematic assessment of face validity, the AMA-convened Physician Consortium for Performance Improvement (PCPI) oversees the measure development process of clinically relevant physician-level performance measures. The scale was used 1-5, where 1=Strongly Disagree; 2= Disagree; 3=Neither Disagree nor Agree; 4= Agree; 5=Strongly Agree o Mean scores were: § Results for Future Fall Risk:4.30 § Results for Risk Assessment for Falls: 4.39 § Plan of Care for Falls: 4.35
Review for Feasibility: 4-H; 17-M; 2-L; 0-I (Meaningful, understandable, and useful to the intended audiences for 4a. Public Reporting/Accountability and 4b. Quality Improvement) Rationale: · Through its inclusion in PQRS, physicians who chose to report on this measure are paid for reporting, not performance. However, the screening element of the measure is also included in the GPRO program, which requires reporting and is beginning to pay for performance; PQRS is expected to move towards being a penalty program in the near future.
Review for Usability: 7-H; 13-M; 2-L; 0-I (3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c.Susceptibility to inaccuracies/ unintended consequences identified 3d. Data collection strategy can be implemented) Rationale: · The measure is collected through administrative claims, electronic claims, and paper medical records. Again, as a long-standing measure, there were no concerns regarding feasibility.
Review for Related and Competing Measures: This measure is related to 0035: Fall Risk Management (NCQA) and 0537: Multifactor Fall Risk Assessment Conducted For All Patients Who Can Ambulate (CMS). There are no competing measures.
Endorsement Public Comments: Not yet available
Endorsement Committee Recommendation: This measure was originally endorsed in 2007 and re-endorsed in 2012. The measure includes three indicators to be reported together across the continuum of care for fall prevention, focusing on people who have fallen more than once or who have had an injurious fall. The measure is based on recommendations from the US Preventive Services Task Force and the American Geriatric Society; the evidence is also supported by the British Geriatric Society and the American Organization of Orthopedic Surgeons. This provider-level measure is currently used in the PQRS program. Because of this measure’s evidence, important, scientific validity, and long-standing use, the Committee agreed it meets the criteria for NQF endorsement. Standing Committee Recommendation for Endorsement: 22-Y; 1-N

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

Measure Specifications

NQF Number (if applicable):
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
Numerator: Most recent BP is less than 140/90 mm Hg And Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure) And Daily Aspirin or Other Antiplatelet Unless Contraindicated And Statin Use
Denominator: Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the Measurement Period. A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months.
Exclusions: History of Gastrointestinal Bleed or Intra-cranial Bleed or documentation of active anticoagulant use during the MP for the Aspirin/Other Anticoagulant component (numerator) of the measure. Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) for the Blood Pressure Control component (numerator) of the composite measure.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Wisconsin Collaborative for Healthcare Quality (WCHQ)
Endorsement Status: The measure is under review by NQF’s Cardiovascular Standing Committee. The Committee has deferred an endorsement recommendation until the measure can be judged side-by-side with NQF #0076 Optimal Vascular Care measure from Minnesota Community Measurement.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Do not support
Preliminary analysis summary
- Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) – both are all-or-none composite measures for ischemic vascular disease . CMS recently removed PQRS #349 because it is duplicative of the Millions Hearts measures. The approach for cardiovascular measures should be aligned in both PQRS/MIPS and MSSP.
- Impact on quality of care for patients: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 – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance.
Does the measure address a program goal or objective? No. This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ?
Is this a high-value measure? Yes. It is a composite measure of important clinical processes and intermediate outcomes for ischemic vascular disease.
Does this measure fill a gap in the program measure set? No. A similar measure was in the PQRS set of measures but recently removed because it duplicates the Million Hearts measures.
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure was tested at the clinician and group level of analysis. Testing data presented in the NQF submission reported testing of 121 clinic sites of 50, 758 patients: signal-to-noise reliability estimates for the measure score was 0.78 (generally accepted to be sufficient for determining performance differences between groups.
Is the measure currently in use? Yes. 2014 performance data for 121 clinics, covering a total of 42,290 patients in Wisconsin found the average clinic performance to be 59% (range 38-75%) – the 90th percentile is 67%. WCHQ publicly reports performance information on group practices and clinics participating in the collaborative; this includes 17 organizations reporting at the group practice level and 121 at the clinic site level, for a total of 50,758 patients.
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not fully harmonized with PQRS #349 (NQF #0076) Optimal Vascular Care that id being removed from the PQRS set.
Is the measure NQF endorsed for the program's setting and level of analysis? No. The measure is under review by NQF’s Cardiovascular Standing Committee. The Committee has deferred an endorsement recommendation until the measure can be judged side-by-side with NQF #0076 Optimal Vascular Care measure from Minnesota Community Measurement.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #10 Dehydration Admission Rate • PQI #11 Bacterial Pneumonia Admission Rate • PQI #12 Urinary Tract Infection Admission Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status: The composite has not been submitted to NQF, but all three component measures are NQF-endorsed as population-level measures for geographic areas: PQI #10 Dehydration Admission Rate (NQF #280)• PQI #11 Bacterial Pneumonia Admission Rate (NQF #279)• PQI #12 Urinary Tract Infection Admission Rate (NQF #281)
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. A risk-model that includes co-morbidities is being devloped.
- Impact on quality of care for patients:This measure encourages appropriate care of acute conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families.
Does the measure address a program goal or objective? Yes. This composite measure supports improved individual and population health
Is this a high-value measure? Yes. This is a composite measure.
Does this measure fill a gap in the program measure set? Yes. MAP identified composite measures as a priority for MSSP.
Measure development status: The submitter notes that the measure is currently used in a CMS program (Physician VBPM), but the measure is undergoing substantial change
Is the measure fully tested for the program's setting and level of analysis? No. The measure is specified for a geographic population. Testing for use in an ACO is needed.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure might be applicable to ACOs if testing is successful at that level of analysis.
Is the measure currently in use? Yes. The measure is used in the VBPM.
Does a review of its performance history raise any concerns? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Composite measures are efficient because they provide more information from a single measure. The measure is aligned with other CMS reporting initiatives.
Is the measure NQF endorsed for the program's setting and level of analysis? No. The composite has not been submitted to NQF, but all three component measures are NQF-endorsed as population-level measures for geographic areas: PQI #10 Dehydration Admission Rate (NQF #280)• PQI #11 Bacterial Pneumonia Admission Rate (NQF #279)• PQI #12 Urinary Tract Infection Admission Rate (NQF #281)
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #1 Diabetes Short-Term Complications Admission Rate • PQI #3 Diabetes Long-Term Complications Admission Rate • PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate • PQI #7 Hypertension Admission Rate • PQI #8 Heart Failure Admission Rate • PQI #13 Angina Without Procedure Admission Rate • PQI #14 Uncontrolled Diabetes Admission Rate • PQI #15 Asthma in Younger Adults Admission Rate • PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area† or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status: This composite measure has not been submitted to NQF. However, 7 of the measures are NQF-endorsed as population-level measures for geographic areas:• PQI #1 Diabetes Short-Term Complications Admission Rate (NQF #272)• PQI #3 Diabetes Long-Term Complications Admission Rate (NQF #274)• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (NQF #275)• PQI #8 Heart Failure Admission Rate (NQF #277)• PQI #14 Uncontrolled Diabetes Admission Rate (NQF #638) • PQI #15 Asthma in Younger Adults Admission Rate (NQF #283)• PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate (NQF #285)In 2012 NQF removed endorsement of two component measures: PQI #7 Hypertension Admission Rate This measure only captures admissions with a primary diagnosis of hypertension. Many admissions for uncontrolled hypertension are for AMI or stroke rather than hypertension and are not captured in this measure. The Committee questioned interpretation of results. Also the documentation from the developer stated ” “Little evidence exists regarding the validity of this indicator,” and “some of the variance in age-sex adjusted rates does not reflect true differences in area performance.”. PQI #13 Angina Without Procedure Admission Rate This measure is looking for inappropriate admissions for angina - not over use of procedures. The measure implies that admission for angina as long as it is accompanied by a procedure is appropriate – the Committee thought this may encourage procedures. Also, coding has changed so that many patients are coded as coronary artery disease rather than angina which is a significant flaw in the measure.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Encourage continued development
Preliminary analysis summary
- Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the ACO level of analysis and submitted to NQF.
- Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs.
Does the measure address a program goal or objective? Yes. This nine component composite measure supports improved individual and population health. Two of the component measures are already in the MSSP measure set. One component - PQI #15 Asthma in Younger Adults Admission Rate – does not apply to Medicare age patients.
Is this a high-value measure? Yes. This is a composite measure.
Does this measure fill a gap in the program measure set? Yes. MAP identified composite measures as a priority for MSSP.
Measure development status: Fully Developed
Is the measure fully tested for the program's setting and level of analysis? No. AHRQ : “We are developing risk adjustment approach and testing at an ACO level.”
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure might be applicable to ACOs if testing is successful at that level of analysis.
Is the measure currently in use? No. Measure currently used in a CMS program, but the measure is undergoing substantial change.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. Two of the component measures are already in the MSSP program (heart failure and COPD readmissions ).
Is the measure NQF endorsed for the program's setting and level of analysis? No. This composite measure has not been submitted to NQF. However, 7 of the measures are NQF-endorsed as population-level measures for geographic areas:• PQI #1 Diabetes Short-Term Complications Admission Rate (NQF #272)• PQI #3 Diabetes Long-Term Complications Admission Rate (NQF #274)• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (NQF #275)• PQI #8 Heart Failure Admission Rate (NQF #277)• PQI #14 Uncontrolled Diabetes Admission Rate (NQF #638) • PQI #15 Asthma in Younger Adults Admission Rate (NQF #283)• PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate (NQF #285)In 2012 NQF removed endorsement of two component measures: PQI #7 Hypertension Admission Rate This measure only captures admissions with a primary diagnosis of hypertension. Many admissions for uncontrolled hypertension are for AMI or stroke rather than hypertension and are not captured in this measure. The Committee questioned interpretation of results. Also the documentation from the developer stated ” “Little evidence exists regarding the validity of this indicator,” and “some of the variance in age-sex adjusted rates does not reflect true differences in area performance.”. PQI #13 Angina Without Procedure Admission Rate This measure is looking for inappropriate admissions for angina - not over use of procedures. The measure implies that admission for angina as long as it is accompanied by a procedure is appropriate – the Committee thought this may encourage procedures. Also, coding has changed so that many patients are coded as coronary artery disease rather than angina which is a significant flaw in the measure.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (Program: Physician Compare; MUC ID: MUC15-402)

Measure Specifications

NQF Number (if applicable):
Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting
Numerator: All symptomatic patients with stroke or death within 30 days of Carotid Artery Stenting
Denominator: All symptomatic patients undergoing Carotid Artery Stenting
Exclusions: Patients being treated with emergent Carotid Artery Stenting (Acute ischemic stroke or Trauma) Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Multicenter Registry in Hospital/Acute Care Facility
Measure Type: Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Fully Developed
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Physician Compare; MUC ID: MUC15-377)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of surgical entropion patients with a postoperative normalized lid position
Numerator: Patients who achieved normalized lid position postoperatively within 90 days of surgery
Denominator: Patients aged 18 years or older with a diagnosis of involutional entropion who underwent a surgical procedure for the condition
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Physician Compare; MUC ID: MUC15-396)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells.
Numerator: Patients achieved Grade 0 anterior chamber cells at 30 days after onset of treatment
Denominator: Patients aged 18 years of older who underwent treatment for acute anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Acute Anterior Uveitis: Post-treatment visual acuity (Program: Physician Compare; MUC ID: MUC15-394)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis
Numerator: Best corrected visual acuity of 20/40 or better achieved within 90 days following treatment initiation OR Patient's visual acuity returned to baseline value within 90 days of treatment initiation
Denominator: Patients aged 18 years of older who underwent treatment for acute anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-412)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting
Numerator: The number of patients who demonstrate an improvement in the Villalta score following ilio-femoral venous stenting as assessed between 3-6 months post procedure
Denominator: The total number of patients who underwent ilio-femoral venous stenting with clinical assessment using the Villalta score at baseline and between 3-6 months post-procedure
Exclusions: Patients with a history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
- Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms.
Does the measure address a program goal or objective? Yes. This is an outcome measure assessing improvement in patients’ symptoms after vascular stenting procedure.
Is this a high-value measure? Yes. It is a patient-centered outcome measure.
Does this measure fill a gap in the program measure set? Yes. This is an outcome measure for a common procedure.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? No. Level of Analysis: The Villalta score has been validated as an objective measure to assess post-thrombotic syndrome, an important cause of morbidity in patients with iliofemoral venous disease in group practices. NOTE: This is only testing of the instrument; the performance measure requires testing also for clinicians and groups
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure needs testing for reliability and validity as a performance measure for individuals and groups.
Is the measure currently in use? No.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Physician Compare; MUC ID: MUC15-399)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells.
Numerator: Patients achieved Grade 0 anterior chamber cells at 30 days after onset of treatment AND Patients managed at 60 days with dose of topical corticosteroids or prednisolone acetate (or equivalent) 1% 3X/days or less
Denominator: Patients aged 18 years of older who underwent treatment for chronic anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Chronic Anterior Uveitis: Post-treatment visual acuity (Program: Physician Compare; MUC ID: MUC15-397)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis
Numerator: Best corrected visual acuity of 20/40 or better achieved within 90 days following treatment initiation OR Patient's visual acuity returned to baseline value within 90 days of treatment initiation
Denominator: Patients aged 18 years of older who underwent treatment for chronic anterior uveitis
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Common femoral arterial access site complication (Program: Physician Compare; MUC ID: MUC15-424)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious
Numerator: Number of percutaneous arterial access procedures with a vascular complication from common femoral arterial access using a system of 8Fr or less in size including pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious arteritis.
Denominator: All percutaneous groin arterial access procedures using access sheath sizes of 8Fr or less. For patients undergoing bilateral arterial access each access site should be considered a separate event.
Exclusions: Exclusions: Patients with a history of surgical lower extremity bypass. Exceptions: Patients with recent groin arterial access with uncertain vascular access status (i.e. outside arterial procedure, uncertain if complication occurred); Recent arterial vascular access procedure with complication referred for subsequent treatment
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Program: Physician Compare; MUC ID: MUC15-461)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less
Numerator: Numerator is the number of patients who completed external beam radiation within 60 days from initiation for locally advanced cervical cancer with curative intent
Denominator: Denominator is the number of women being treated with chemoradiation for locally advanced cervical cancer (ICD-9 180.9; ICD-10 C53.9) Radiation therapy CPT codes 77301, 77338, 77300, 77386, 77295, 77300, 77334, 77412
Exclusions: Women who not being treated with curative intent Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry, Survey
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing;
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Physician Compare; MUC ID: MUC15-370)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery
Numerator: Visual acuity of 20/40 of better achieved within 90 days following corneal graft surgery
Denominator: Patients aged 18 years or older who underwent a corneal graft procedure with one of the following indications for surgery: endothelial dystrophy, post cataract surgery edema, failed corneal graft, ectatic disease, anterior/stromal dystrophy, or corneal opacity
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Diabetic Macular Edema: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-393)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months
Numerator: Patients who achieved a loss a loss in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of diabetic macular edema who received anti-VEGF injections, intravitreal injections, or laser photocoagulation therapy
Exclusions: Denominator Exclusions: Patients with ophthalmic complications of diabetic retinopathy including neovascular glaucoma, traction retinal detachment, vitreous hemorrhage, history of vitreous surgery, history of retinal surgery, development of retinopathy in the fellow eye Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Documentation of offering a trial of conservative management prior to fecal incontinence surgery (Program: Physician Compare; MUC ID: MUC15-440)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention
Numerator: Number of patients who have been offered conservative management for fecal incontinence prior to surgical intervention. These would be identified by chart review or entry into the PFD Registry. Therapies meeting the criteria for conservative management would include high fiber diet, bulking agents, anti-diarrheal medications for patients with diarrhea, scheduled toileting, Kegel exercises, biofeedback, pelvic floor physical therapy, and fecal disimpaction in patients who are constipated.
Denominator: The number of patients undergoing surgery for the indication of fecal incontinence will be included. Fecal incontinence surgeries will include the following CPT codes: ICD9 0377T anal bulking injection; 46750 for overlapping anal sphincteroplasty, 46761 (anal sphincteroplasty with levator plication), 46762 (ICD10 0DHQ0LZ-0DHQ4LZ) for implantation of artificial anal sphincter, and 64561, 64581, 64590, 77002 for sacral neuromodulation and fecal incontinence will be defined by the following ICD-9/ICD-10 codes: ICD9: 787.60 (full incontinence of feces), 787.62 (fecal smearing), 787.63 (fecal urgency); ICD10: R15.9 (anal sphincter, fecal incontinence); R15.1 (fecal smearing); R15.2 (fecal urgency)
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Documentation of offering a trial of conservative management prior to urgency incontinence surgery (Program: Physician Compare; MUC ID: MUC15-441)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention
Numerator: Number of patients that who have been offered conservative management for urgency urinary incontinence prior to surgical intervention. These would be identified by chart review or entry into the PFD Registry. Therapies meeting the criteria for conservative management include would include: behavioral modifications (avoiding bladder irritants, excessive fluid intake), Kegel exercises, pelvic floor physical therapy; pharmacologic management.
Denominator: The number of patients undergoing surgery for the indication of urgency urinary incontinence will be included. Urgency incontinence surgeries will include the following CPT codes: ICD9 64566 for posterior tibial nerve stimulation; 64561, 64581, 64590, 77002 for sacral neuromodulation; 52287 chemodenervation-intradetrusor botulinum injections. Urgency incontinence will be defined by the following ICD-9/ICD-10 codes: ICD9: 788.31 (urge incontinence), 788.63 (urinary urgency), 788.41 (urinary frequency), 788.43 (nocturia), 788.33 (mixed urinary incontinence) 788.34 (incontinence without sensory awareness), 788.36 (nocturnal enuresis), 788.37 (continuous leakage), 788.38 (overflow incontinence), 788.39 (other incontinence), 596.59 (detrusor overactivity), 596.54 (neurogenic bladder), 596.51 (overactive bladder). ICD10: N32.81 (overactive bladder), N32.89 (other specified disorders of bladder), N32.9 (other unspecified disorder of bladder), N39.41 (urge incontinence), N39.42 (incontinence w/o sensory awareness), N39.45 (continuous leakage), N39.44 (nocturnal enuresis), N39.46 (mixed incontinence), N39.490(other specified urinary incontinence - reflex or total), N39.498 (total incontinence), R32 (enuresis NOS), R39.81 (urinary incontinence associated with cognitive impairment), R39.81 (functional urinary incontinence)
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Efficacy of uterine artery embolization for symptomatic uterine fibroids (Program: Physician Compare; MUC ID: MUC15-423)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure
Numerator: Number of patients who report symptomatic improvement following uterine artery embolization performed for treatment of fibroids using a disease-specific survey instrument
Denominator: All patients referred for uterine artery embolization who completed a disease specific survey instrument at baseline and 6 months following the procedure.
Exclusions: Exclusions: Patients with incomplete survey data Exceptions: Patients with suspected adenomyosis
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Survey
Measure Type: Patient Reported Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-379)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months
Numerator: Patients who achieved a lost in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of exudative age-related macular degeneration being treated with anti-vegf agents
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Physician Compare; MUC ID: MUC15-372)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition
Numerator: Patient visits where the eye(s) intraocular pressure (IOP) was below a specified threshold based on the severity of their glaucoma. - Mild stage glaucoma: IOP <= 22mm HG - Moderate stage glaucoma: IOP <= 18 mm HG - Severe stage: IOP <= 15 mm HG
Denominator: Patients aged between 40 and 85 years, with a minimum of 4 office visits during the prior 24 months, with a diagnosis of glaucoma and with documentation of the severity of their condition.
Exclusions: Denominator Exclusions: Patients with a diagnosis of low tension glaucoma OR Eyes with a documented severity of indeterminate stage OR Eyes with absolute glaucoma blindness OR Patients who had glaucoma incisional surgery performed within the last 90 days OR Patients with visual acuity findings of count fingers, hand motion, light perception or no light perception Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Physician Compare; MUC ID: MUC15-374)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level.
Numerator: Patients eyes with a reduction in intraocular pressure = 20% from their pretreatment level
Denominator: Patients aged between 40 and 85 years who underwent laser trabeculoplasty
Exclusions: Denominator Exclusions: Eyes with absolute glaucoma blindness OR Patients with visual acuity findings of count fingers, hand motion, light perception or no light perception Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Hepatitis A vaccination for patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-210)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis A vaccination
Numerator: Patients with diagnosis of cirrhosis who have had a hepatitis A vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis A vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of analysis not specified
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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)

Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Physician Compare; MUC ID: MUC15-220)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of chronic Hepatitis C that have documented hepatitis B vaccination
Numerator: Patients with diagnosis of chronic Hepatitis C who have had a hepatitis B vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of chronic Hepatitis C
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis B vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: A similar measure was not endorsed by NQF because it specified only receipt of the first dose of vaccine which is not thought to be adequate for protection.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
- Impact on quality of care for patients:Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes
Does the measure address a program goal or objective? No. The measure is not an eCQM, tested or in any program. It is not duplicative of any current measures but is related to NQF #0399 Hepatitis C: Hepatitis A Vaccination
Is this a high-value measure? No. Process measure many steps removed from the outcome.
Does this measure fill a gap in the program measure set? Yes. This measure would compliment other hepatitis measures.
Measure development status: Field Testing –level of testing not specified
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. A similar measure was not endorsed by NQF because it specified only receipt of the first dose of vaccine which is not thought to be adequate for protection.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

Hepatitis B vaccination for patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-211)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis B vaccination
Numerator: Patients with diagnosis of cirrhosis who have had a hepatitis B vaccination during or prior to the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Patient declined Hepatitis B vaccine or contraindicated
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of analysis not specified
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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)

Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Physician Compare; MUC ID: MUC15-229)

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Patients with undetectable HCV RNA 11 weeks after cessation of treatment
Denominator: All patients aged 18 years and older with a diagnosis of hepatitis C who are initiating or receiving antiviral treatment during the measurement period
Exclusions: Measure only needs to be reported if initiation of antiviral treatment took place before October of the measurement year (11 weeks before the end of the measurement period)
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Gastroenterological Association
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Early Development
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Physician Compare; MUC ID: MUC15-230)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV
Numerator: Patients with an HIV test during period extending from 30 days before STD diagnosis to 30 days after STD diagnosis
Denominator: Patients diagnosed with an acute STD during the one year period ending 30 days prior to the end of the measurement year. STDs include: syphilis and gonorrhea
Exclusions: Denominator Exclusions: Patients who have HIV infection.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Measure designed so that all relevant data should be available/abstractable from EHR
Measure Type: Process
Steward: Centers for Disease Control and Prevention
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Currently in Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-413)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting
Numerator: The number of patients who demonstrate improvement in the venous clinical severity score following ilio-femoral venous stenting as assessed 3-6 months post-procedure
Denominator: The total number of patients who underwent ilio-femoral venous stenting with application of the venous clinical severity both at baseline and at 3-6 months post-procedure.
Exclusions: Patients with history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Intermediate Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Endorsed
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? Yes. This is an outcome measure.
Is this a high-value measure? Yes. This is an outcome measure
Does this measure fill a gap in the program measure set? Yes. This is an outcome measure to assess effectiveness of treatment procedure.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Level of Analysis tested: Group Practice, Academic medical centers
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No . This measure is very similar and overlapping with MUCFIFTEEN-412 Assessment of post-thrombotic syndrome following ilio-femoral venous stenting
Is the measure NQF endorsed for the program's setting and level of analysis? No. Endorsed

Measure Specifications

NQF Number (if applicable):
Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer
Numerator: Patients who have Ovarian cancer / fallopian tube cancer ( ICD-9= 183.0 (Ovarian cancer) 183.2 (Fallopian tube cancer) AND received IP chemo within 42 days from surgery
Denominator: All patients who underwent debulking surgery for ovarian cancer. CPT coding may vary but possibilities are: 58950 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy 58951 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphandenectomy 58952 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) 58953 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking 58954 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphandenectomy and limited para-aortic lymphadenectomy 58956 – Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 58957 – Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed 58958 - Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
Exclusions: Patients who received Neoadjuvant Chemotherapy Patients with non-epithelial cancer Patients who had the IP chemotherapy not offered (and or to be offered IP chemotherapy after the first cycle of IV chemotherapy) by the surgeons for any of the listed reasons: a- Those who had bowel resection as part of their debulking surgery. b- Had multiple abdominal surgeries that impede the futility of IP chemotherapy. c- Patients’ who have had a sub optimal debulking d- Any other medical reason(s) that contraindicated IP chemotherapy (e.g.: peritonitis, inflammatory bowel disease, liver failure, renal failure. etc.) Exceptions: Patients who are pregnant at the time of diagnosis ( ICD-9= 640.0 – 669.9 and V22.0 – V23.9)
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Measure Specifications

NQF Number (if applicable):
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
Numerator: Most recent BP is less than 140/90 mm Hg And Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure) And Daily Aspirin or Other Antiplatelet Unless Contraindicated And Statin Use
Denominator: Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the Measurement Period. A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months.
Exclusions: History of Gastrointestinal Bleed or Intra-cranial Bleed or documentation of active anticoagulant use during the MP for the Aspirin/Other Anticoagulant component (numerator) of the measure. Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) for the Blood Pressure Control component (numerator) of the composite measure.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Wisconsin Collaborative for Healthcare Quality (WCHQ)
Endorsement Status: The NQF Cardiovascular Standing Committee has deferred endorsement recommendation on this measure until they can evaluate it side-by-side with NQF#0076 Optinal Vascular Care.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: NA
Does the measure address a program goal or objective? .
Measure development status: Fully Developed
Is the measure NQF endorsed for the program's setting and level of analysis? The NQF Cardiovascular Standing Committee has deferred endorsement recommendation on this measure until they can evaluate it side-by-side with NQF#0076 Optinal Vascular Care.

Minimally invasive surgery performed for patients with endometrial cancer (Program: Physician Compare; MUC ID: MUC15-452)

Measure Specifications

NQF Number (if applicable):
Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer
Numerator: Number of patients with endometrial cancer (ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 Other specified sites of body of uterus) who underwent minimally invasive hysterectomy. Minimally invasive is defined as laparoscopic or robotic approaches (CPT codes: 58541-44, 58550, 58552-54, 58570-73) with or without vaginal assistance (58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-94).
Denominator: Number of patients with endometrial cancer (ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 Other specified sites of body of uterus) who underwent hysterectomy. This includes hysterectomy via laparotomy (58150, 58152, 58180, 58200, 58210), laparoscopy, robotic, or vaginal (see CPT codes in numerator).
Exclusions: Patients with endometrial cancer who did not undergo hysterectomy Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Physician Compare; MUC ID: MUC15-296)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures.
Numerator: All patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area Definition: Corneal Injury: Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded.
Denominator: All patients who undergo anesthesia care, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery.
Exclusions: Exclusions: none Exceptions: Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury before anesthesia care.
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Society of Anesthesiologists
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Adverse outcome measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

NMSC: Biopsy Reporting Time - Pathologist (Program: Physician Compare; MUC ID: MUC15-216)

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 5 business days from the time when the tissue specimen was received by the pathologist.
Denominator: All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease).
Exclusions: Pathologists/Dermatopathologists providing a second opinion on a biopsy.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-392)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months
Numerator: Patients who achieved a loss a loss in visual acuity of = 0.3 logMar
Denominator: Patients aged 18 years or older with a diagnosis of nonexudative AMD and taking AREDS supplements
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Physician Compare; MUC ID: MUC15-215)

Measure Specifications

NQF Number (if applicable):
Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient.
Numerator: Number of cutaneous biopsies by the clinician consistent with basal cell carcinoma or squamous cell carcinoma (to include in situ disease) for which the patient was notified of their final biopsy pathology findings within 15 business days from the time when the biopsy was performed. Distinct dates of service resulting in an eligible patient procedure should be reported separately.
Denominator: All cutaneous biopsies by the clinician consistent with cutaneous basal or squamous cell carcinoma (including in situ disease).
Exclusions: Pathology reports for tissue specimens produced from excision.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:This is an important communications measure
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Non-Recommended PSA-Based Screening (Program: Physician Compare; MUC ID: MUC15-1019)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening.
Numerator: Patients who receive a PSA-based screening test during the measurement period.
Denominator: Men of any age with an encounter during the measurement period.
Exclusions: Denominator exclusions: Men who had an active diagnosis or history of prostate cancer diagnosis, an active diagnosis of dysplasia of the prostate, or an elevated PSA test result in the year prior to the measurement period (>4.0 nanograms/milliliter [ng/mL]).
HHS NQS Priority: Making Care Safer
HHS Data Source: This measure is intended to be an electronic Clinical Quality Measure (eCQM) and will use EHR data exclusively.
Measure Type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:This measure provides patients and other stakeholders with information about clinicians that do not follow guidelines and contribute to unnecessary costs.
Does the measure address a program goal or objective? .
Measure development status: Early Development
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Non-selective beta blocker use in patients with esophageal varices (Program: Physician Compare; MUC ID: MUC15-209)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period
Numerator: Patients with diagnosis of esophageal varices on non-selective beta blocker in the measurement period
Denominator: All patients with diagnosis of esophageal varices
Exclusions: Exclusions: none Exceptions: Intolerance to non-selective beta blocker, pulse < 60, systolic BP < 90, diastolic BP < 50
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of testing unknown
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Over-utilization of mesh in the posterior compartment (Program: Physician Compare; MUC ID: MUC15-436)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.
Numerator: Number of patients undergoing surgery for pelvic organ prolapse in the posterior compartment with a synthetic mesh augment is placed in the posterior compartment.
Denominator: Number of patients undergoing surgery for pelvic organ prolapse which includes the posterior compartment. The prolapse codes for ICD9 -> ICD-10 include: 618.04 -> N81.6, Rectocele
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (Program: Physician Compare; MUC ID: MUC15-928)

Measure Specifications

NQF Number (if applicable): 2103
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.
Numerator: 712: Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during the four month measurement period. #711: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five. #710: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.
Denominator: 712: Adult patients age 18 and older with the diagnosis of major depression or dysthymia. #711: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine. #710: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine.
Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: EHR, Paper medical record
Measure Type: Outcome
Steward: MN Community Measurement
Endorsement Status: Never Submitted
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? Yes

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Fully Developed
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Patient reported outcomes following ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-411)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting
Numerator: The number of patients who demonstrate improvement on a disease-specific patient reported quality of life score at 3-6 months following ilio-femoral venous stenting
Denominator: The total number of patients undergoing ilio-femoral venous stenting who received a baseline and follow-up disease specific patient reported quality of life score at 3-6 months
Exclusions: Patients with a history of lower extremity or pelvic vein surgery. Exceptions: Patients with a history of pelvic or lower extremity orthopedic surgery. Patients with debilitating osteoarthritis involving the hips, knees, or ankles.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure Type: Patient Reported Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Patient-Reported Functional Communication (Program: Physician Compare; MUC ID: MUC15-313)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment
Numerator: A standardized, patient-reported functional communication assessment is documented in the record
Denominator: Patients age 18 years and older on the date of the encounter with a diagnosis of a permanent, bilateral sensorineural hearing loss (ICD-10 H90.3, H91.03, H91.3) and are seen for audiologic testing (CPT 92552, 92553, 92557, 92591, 92626)
Exclusions: 1) Patient has a hearing loss that requires medical or surgical intervention 2) Patient refuses to participate/complete patient-reported functional hearing assessment 3) Patient is unable to perform functional hearing assessment due to other complicated health factors, language delay, or developmental delay Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: AQC/ASHA
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Measures using patient reported data are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Performance of objective measure of functional hearing status (Program: Physician Compare; MUC ID: MUC15-307)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition
Numerator: An objective measure of functional hearing status using a standardized open-set speech recognition test (words, short phrases, or sentences) is documented.
Denominator: Patients age 5 years and older on the date of the encounter diagnosed with a permanent, bilateral sensorineural hearing loss (ICD-10: H90.3, H91.03, H91.3) and seen for audiologic testing (CPT 92552, 92553, 92557, 92579, 92582, 92591, 92626)
Exclusions: 1) Patient has a hearing loss that requires medical or surgical intervention 2) Patient refuses to participate 3) Patient is unable to perform functional hearing assessment due to other complicated health factors, language delay or developmental delay. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Audiology Quality Consortium/American Speech Language Hearing Association
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Program: Physician Compare; MUC ID: MUC15-465)

Measure Specifications

NQF Number (if applicable):
Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy.
Numerator: Women whose hysterectomy is classified as a radical hysterectomy and includes removal of parametrial tissue, vaginal tissue and a portion of the uterosacral ligaments. CPT 58210, 58285, or ICD9 codes 68.6, 68.61, 68.69, 68.7, 68.71, 68.79
Denominator: Women with histologically confirmed stage IB1-IIA cervical cancer who undergo hysterectomy. CPT codes 58210, 58285, 58150, 58152, 58180, 58200, 58956, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58572, 58571, 58573, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294 or ICD9 codes 68.6, 68.61, 68.69, 68.7, 68.71, 68.79, 68.3, 68.31, 68.39, 68.4, 68.41, 68.49, 68.5, 68.51, 68.59, 68.6, 68.61, 68.69, 68.9
Exclusions: Women who undergo primary surgery that is not a hysterectomy. Women who undergo secondary surgery after primary radiotherapy or chemoradiation. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing NOTE: Need data on current performance/
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Measure Specifications

NQF Number (if applicable):
Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer
Numerator: Patients who have Ovarian cancer / fallopian tube cancer ( ICD-9= 183.0 (Ovarian cancer) 183.2 (Fallopian tube cancer) AND received IV chemo within 42 days from surgery
Denominator: All patient who underwent debulking surgery for ovarian cancer. CPT coding may varies but those are the possibilites.58950 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy 58951 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphandenectomy 58952 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) 58953 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking 58954 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphandenectomy and limited para-aortic lymphadenectomy 58956 – Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 58957 – Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed 58958 - Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors, with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
Exclusions: Patients who received Neoadjuvant Chemotherapy Patients with non-epithelial cancer Exceptions: Patients who are pregnant at the time of diagnosis ( ICD-9= 640.0 – 669.9 and V22.0 – V23.9)
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Measure Specifications

NQF Number (if applicable):
Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy)
Numerator: Cervical cancer: 180.0, 180.1, 180.9, parametrium 183.4, vagina 184.0, Positive lymph nodes draining the cervical basin secondary : ICD9 codes 196.2, 196.6, 197.6, radiation therapy CPT codes: IMRT 77418, 0073T, HDR brachy 77785-77787,
Denominator: Cervical cancer: 180.0, 180.1, 180.9 , parametrium 183.4, vagina 184.0, Positive lymph nodes draining the cervical basin secondary : ICD9 codes 196.2, 196.6, 197.6
Exclusions: Small cell, melanoma and other cervical histologies that might be treated with primary chemotherapy. Secondary cervical cancers Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Endorsed; MUC same as endorsed version: Yes; NQF endorsement review - 2015
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed; MUC same as endorsed version: Yes; NQF endorsement review - 2015

Potential Opioid Overuse (Program: Physician Compare; MUC ID: MUC15-1169)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage.
Numerator: Patients of the Medicare prescribing provider whose daily morphine equivalent dose (MED) is greater than 90 mg for at least 90 consecutive days.
Denominator: Patients of the Medicare prescribing provider that are enrolled in a Part D Plan and who had two or more prescription claims totaling > 15 days supply for an opioid, on two separate occasions during the measurement year.
Exclusions: Denominator exclusions: • Patients receiving palliative or hospice treatment during the measurement period • Patients with cancer during the measurement period • Patients with critical limb ischemic pain during the measurement period • Patients with idiopathic pulmonary fibrosis during the measurement period • Patients with refractory angina during the measurement period • Patients with sickle cell disease during the measurement period
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims
Measure Type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Never submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Early Development
Is the measure NQF endorsed for the program's setting and level of analysis? Never submitted

PQI 91 Prevention Quality Acute Composite (Program: Physician Compare; MUC ID: MUC15-577)

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #10 Dehydration Admission Rate • PQI #11 Bacterial Pneumonia Admission Rate • PQI #12 Urinary Tract Infection Admission Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status:
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders.

Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Physician Compare; MUC ID: MUC15-576)

Measure Specifications

NQF Number (if applicable):
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)
Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: • PQI #1 Diabetes Short-Term Complications Admission Rate • PQI #3 Diabetes Long-Term Complications Admission Rate • PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate • PQI #7 Hypertension Admission Rate • PQI #8 Heart Failure Admission Rate • PQI #13 Angina Without Procedure Admission Rate • PQI #14 Uncontrolled Diabetes Admission Rate • PQI #15 Asthma in Younger Adults Admission Rate • PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
Denominator: Population ages 18 years and older in metropolitan area† or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
Exclusions: See each component measure for exclusions. http://www.qualityindicators.ahrq.gov/modules/PQI_TechSpec.aspx
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims
Measure Type: Composite
Steward: Agency for Healthcare Research & Quality
Endorsement Status:
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders.
Measure development status: Fully Developed

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

Proportion admitted to hospice for less than 3 days (Program: Physician Compare; MUC ID: MUC15-415)

Measure Specifications

NQF Number (if applicable): 216
Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there
Numerator: Patients who died from cancer and spent fewer than three days in hospice
Denominator: Patients who died from cancer who were admitted to hospice
Exclusions: None
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Society of Clinical Oncology
Endorsement Status: Never Submitted
Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: This measure is NQF-endorsed (NQF#0216); full specifications and testing information are provided.
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Summary of NQF Endorsement Review

Year of Most Recent Endorsement Review: 2011
Project for Most Recent Endorsement Review: Cancer Endorsement Maintenance 2011
Review for Importance: The measure meets the Importance criteria.(1a. High Impact; 1b. Performance Gap; 1c. Evidence)1a. Impact: H-14; M-3; L-0; I-0; 1b. Performance Gap: H-13; M-3; L-1; I-0; 1c. Evidence: Y-16, N-1, I-0Rationale:• It is well documented that short lengths of stay in hospice compromises patients' quality of care and that there is a substantial portion of hospice patients that are referred within 1-3 days of death.• The measure affects a large number of patients and is high impact.• Many cancer patients die in a hospital receiving futile care until the end. Referring patients to hospice, when appropriate, addresses patient preferences, improves quality of care, and reduces health care costs.• The Steering Committee noted that poor performance on this measure would indicate that providers are failing to have direct conversations with their patients about the futility of further treatment and the benefits of hospice care.• The committee felt the measure developer provided good evidence to support that the concept that hospice referral would mean increased quality of care.
Review for Scientific Acceptability: The measure meets the Scientific Acceptability criteria.(2a. Reliability – precise specifications, testing; 2b. Validity – testing, threats to validity)2a. Reliability: H-14; M-3; L-1; I-0; 2b. Validity: H-13; M-4; L-0; I-0Rationale:• Steering Committee members questioned why three days was selected as the numerator. The developer noted that three days is the minimum lowest bar; seven days may be a better indicator of quality of care. Also, data was more easily obtained with the three day threshold than the seven day threshold.• The measure is well specified.• The reliability testing for the measure is appropriate and demonstrates the reliability of the measure.• Face validity of the measure was demonstrated.
Review for Feasibility: H-12; M-5; L-0; I-0(4a. Clinical data generated during care process; 4b. Electronic data; 4c.Susceptibility to inaccuracies/ unintended consequences identified 4d. Data collection strategy can be implemented)Rationale:• The measure is reported using claims data and is feasible to implement.• Steering Committee members noted that this measure in conjunction with measure #0215 would prevent providers from not sending patients to hospice because of the fear that the patient would die in the next 3 days and prevents providers from making patient care decisions about sending patients to hospice based on measure performance.
Review for Usability: H-11; M-6; L-0; I-0(Meaningful, understandable, and useful to the intended audiences for 3a. Public Reporting and 3b. Quality Improvement)Rationale:• The measure is usable for public reporting, as it captures the use of hospice for appropriate patients.• The measure is useful for QI, particularly when comparing facilities with similar patient populations to see if there are irregularities in achieving this measure.• The measure is in use through ASCO’s QOPI program.
Endorsement Public Comments: Commenters indicated support for the measure.
Endorsement Committee Recommendation: Y-17; N-0Rationale: The Steering Committee found that the measure affects a large patient population and will help identify when facilities are providing overly aggressive, futile care to patients rather than referring them to hospice.

Rate of adequate percutaneous image-guided biopsy (Program: Physician Compare; MUC ID: MUC15-420)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report.
Numerator: Number of percutaneous image-guided biopsy procedures performed associated with a specimen sample considered adequate for pathological analysis.
Denominator: Number of percutaneous image-guided biopsies performed
Exclusions: Repeat biopsy procedures performed at the same site following an initial inadequate sample
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Composite
Steward: Society of Interventional Radiology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies.
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Route of hysterectomy (Program: Physician Compare; MUC ID: MUC15-437)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who underwent vaginal hysterectomy
Numerator: Total number of patients undergoing vaginal hysterectomy (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554)
Denominator: Total number of patients undergoing hysterectomy of any type. (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554, 58544, 58570, 58571, 58572, 58573, 58541, 58542, 58543, 58150, 58152, 58180)
Exclusions: Patients with a preoperative diagnosis of cancer (applies to both numerator and denominator, ICD-10 codes) Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Intermediate Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Patients and other stakeholders are interested in how hysterectomies are performed.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Screening endoscopy for varices in patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-251)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of cirrhosis that have documented endoscopy
Numerator: Patients with diagnosis of cirrhosis that have documented endoscopy in the measurement period
Denominator: All patients with diagnosis of cirrhosis
Exclusions: Exclusions: none Exceptions: Currently taking non-selective beta – blocker, life expectancy of < 1 year, patient declines
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: NA
Preliminary analysis summary
- Impact on quality of care for patients:Early detection of varices in cirrhotic patients can improve long term survival
Does the measure address a program goal or objective? No. The measure is not an eCQMs and has not been tested. The measure is not duplicative of any measures currently in the measure list.
Is this a high-value measure? No. This is a screening measure but earlier detection can improve outcomes.
Does this measure fill a gap in the program measure set? Yes. There are no measures that focus on endoscopy in the current measures list.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? N/A
Is the measure currently in use? N/A
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. The measure is not in use and is not currently in any of the MAP Families.
Is the measure NQF endorsed for the program's setting and level of analysis? No. Never Submitted

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

Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Physician Compare; MUC ID: MUC15-217)

Measure Specifications

NQF Number (if applicable):
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
Numerator: Patients with a diagnosis of Chronic Hepatitis B that have had a documented abdominal US, CT Scan, or MRI in the measurement period
Denominator: All patients with diagnosis of Chronic Hepatitis B
Exclusions: Exclusions: none Exceptions: All patients with known diagnosis of hepatoma, life expectancy less than 1 year, or patient declined screening during the measurement.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: NA
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of testing not indicated
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

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

Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Physician Compare; MUC ID: MUC15-375)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively
Numerator: Patients who achieved an improvement in MRD postoperatively compared to their preoperative level
Denominator: Patients aged 18 years or older with a diagnosis of acquired involutional ptosis who underwent a surgical procedure for the condition
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure Type: Outcome
Steward: American Academy of Ophthalmology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Measure Specifications

NQF Number (if applicable):
Description: Uterine cancer patients with adequate surgical staging performed with a grade 3 tumor and deep uterine wall invasion.
Numerator: Number of women with a grade 3 endometrial cancer identified with greater than 50% myometrial invasion who have a surgical staging procedure with lymph node removals
Denominator: Total number of women with a grade 3 endometrial cancer ( ICD-9 codes: 182 malignant neoplasm of body of uterus; 182.0 Corpus uteri, except isthmus; 182.1 Isthmus; 182.8 ) undergoing surgery who are found to have greater than 50% myometrial invasion
Exclusions: Women with poor performance status or medical co-morbidities in which increased surgical time or staging procedures place patient at significant risk or women identified preoperatively with advanced stage disease or treated with preoperative chemotherapy and/or radiation if not a surgical candidate Exceptions: Women with poor performance status or medical co-morbidities in which increased surgical time or staging procedures place patient at significant risk or women identified preoperatively with advanced stage disease or treated with preoperative chemotherapy and/or radiation if not a surgical candidate
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Physician Compare; MUC ID: MUC15-212)

Measure Specifications

NQF Number (if applicable):
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.
Numerator: Patients with diagnosis of Crohn’s disease who have had a colonoscopy in the measurement period or 1 year prior to measurement year
Denominator: All patients with diagnosis of colonic Crohn’s Disease
Exclusions: Exclusions: none Exceptions: Diagnosis of colonic Crohn’s Disease for < 10 years, isolated small bowel Crohn’s disease, life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of testing unknown
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Physician Compare; MUC ID: MUC15-221)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of Ulcerative Colitis for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period.
Numerator: Patients with diagnosis of Ulcerative Colitis who have had a colonoscopy in the measurement period or 1 year prior to measurement year
Denominator: All patients with diagnosis of Ulcerative Colitis
Exclusions: Exclusions: none Exceptions: Diagnosis of colonic Ulcerative Colitis for < 10 years, life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing – level of testing not indicated
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Physician Compare; MUC ID: MUC15-208)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period
Numerator: Patients with diagnosis of Barrett's Esophagus who have had an upper endoscopy during the measurement period or the four years prior to the measurement period
Denominator: All patients with diagnosis of Barrett’s Esophagus
Exclusions: Exclusions: None Exceptions: Denominator: Life expectancy of < 1 year, patient declines
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Field Testing; level of testing unknown
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Testing for uterine disease prior to obliterative procedures (Program: Physician Compare; MUC ID: MUC15-439)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852).
Numerator: Number of patients that were asked about abnormal uterine or postmenopausal bleeding, or those that had an ultrasound and/or endometrial sampling of any kind. These would be identified by chart review or entry into the PFD Registry.
Denominator: CPT code 57120- colpocleisis
Exclusions: Prior hysterectomy Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Program: Physician Compare; MUC ID: MUC15-460)

Measure Specifications

NQF Number (if applicable):
Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy
Numerator: Number of patients who receive brachytherapy as part of their treatment for cervical cancer (Cervical cancer ICD-10 dx code C53.9) CPT 77785, 77786, 77787, 77761, 77762, 77763
Denominator: All patients undergoing primary radiation for cervical cancer (cervical cancer diagnosis code C53.9) with curative intent: 77385, 77386, 77402, 77407, 77412
Exclusions: Patients receiving palliative radiation, patients with stage IVB Exceptions: Patients on clinical trial
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Program: Physician Compare; MUC ID: MUC15-463)

Measure Specifications

NQF Number (if applicable):
Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy.
Numerator: Numerator is the number of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. ICD9 codes 180.0-180.9, CPT codes 96409, 96411, 96417.
Denominator: Number of patients with stage IIB-IV cervical cancer who receive primary radiation therapy. ICD9 codes 180.0-180.9, CPT codes 57155, 57156, 77261-77299, 77300-77399, 77401-77421, 77785, 77786, 77787, 77799.
Exclusions: Patients who have a medical contraindication to receipt of platinum-based chemotherapy should receive an alternative chemotherapy agent that has been demonstrated to have clinical benefit in patients with cervical cancer. Exceptions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: Society of Gynecologic Oncology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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: Physician Compare; MUC ID: MUC15-179)

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings.
Numerator: Number of pathologically-proven primary SCCis or SCC-KA lesions on the trunk (chest, back, abdomen) that are 1 cm or smaller in immunocompetent patients treated by the provider utilizing Mohs surgery.
Denominator: All pathologically-proven primary SCCis or SCC-KA lesions on the trunk (chest, back, abdomen) that are 1 cm or smaller in immunocompetent patients treated by the provider within the reporting period.
Exclusions: Exclusions: • Patients with a genetic syndrome that increases their risk for skin cancer. • Tumors in areas of previous radiation therapy. • Tumors that have pathologically documented areas of dermal invasion, or dermal invasion is found on any stage if Mohs surgery is performed. • Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample. • Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Doing Mohs surgery is often advertised by clinicians to encourage consultation with their practice.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Physician Compare; MUC ID: MUC15-178)

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings.
Numerator: Number of pathologically-proven primary superficial BCC’s treated by the provider utilizing Mohs surgery.
Denominator: All pathologically-proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) on immune-competent patients treated by the provider within the reporting period.
Exclusions: Exclusions: • Tumors that have a pathologically documented mixed histology including a more aggressive histologic subtype, or a more aggressive tumor is found on any stage if Mohs surgery is performed. • Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample. • Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Performing Mohs surgery is often advertised by clinicians to encourage consultation with their practice.
Does the measure address a program goal or objective? .
Measure development status: Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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.

Use Of Preventive Screening Protocol For Transplant Patients (Program: Physician Compare; MUC ID: MUC15-177)

Measure Specifications

NQF Number (if applicable):
Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals.
Numerator: Number of patients receiving sun protection education and a full skin exam once within the reporting period (1 year) by the provider or documentation of either a referral to or completion of these preventative activities by a dermatologist.
Denominator: All organ transplant recipients seen by provider in an outpatient setting within the reporting period.
Exclusions: Exclusions: Documented refusal by patient to schedule follow-up annual screens after documented appropriate counseling on risk for skin cancer.
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Claims, Registry
Measure Type: Process
Steward: American Academy of Dermatology
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Clinician web page
Preliminary analysis summary
- Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
Does the measure address a program goal or objective? Yes. This measure addresses the high-priority domain of population health and prevention.
Is this a high-value measure? No. This is a process measure assessing whether screening and education activities have been performed. While there is good evidence supporting this process, such measures are usually understood to be relatively distant from relevant outcomes.
Does this measure fill a gap in the program measure set? Yes. There are currently only four dermatology-specific measures in the PQRS program; this measure could be considered to fill a gap in that it adds to the limited set of measures specific to this specialty area.
Measure development status: Field Testing
Is the measure fully tested for the program's setting and level of analysis? As reported by the measure submitter, field testing is currently being performed for the appropriate settings (Office- Based Care, Hospital Setting) and levels of analysis (Individual practice, group practice, University hospital setting).
Is the measure currently in use? No.
Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This measure would be unique to the MIPS program in terms of addressing this particular quality issue (screening for skin cancer in organ transplant recipients); the program does not currently include any outcome measures in this area.
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (Program: Physician Compare; MUC ID: MUC15-434)

Measure Specifications

NQF Number (if applicable):
Description: Documentation of ISD prior to procedure
Numerator: Percentage of patients who have documented ISD prior to procedure
Denominator: All patients who underwent the procedure CPT code 51715 and ICD-9 code 599.82
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Registry
Measure Type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Never Submitted
Is the measure specified as an electronic clinical quality measure? No

Preliminary Analysis of Measure

Preliminary analysis result: Spreadsheet
Preliminary analysis summary
- Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
Does the measure address a program goal or objective? .
Measure development status: Early Development, Field Testing
Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted

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

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:

ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements,

Networks of individual practices of ACO professionals,

Partnerships or joint ventures arrangements between hospitals and ACO professionals, or

Hospitals employing ACO professionals, and

Other Medicare providers and suppliers as determined by the Secretary.

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:

Outcome measures that address conditions that are high-cost and affect a high volume of Medicare patients.

Measures that are targeted to the needs and gaps in care of Medicare fee-for-service patients and their caregivers.

Measures that align with CMS quality reporting initiatives, such as PQRS and the VM.

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:

Person and caregiver-centered Experience and Outcomes

CMS wants to specifically focus on patient reported outcome measures (PROMs)

Communication and Care Coordination

Measures addressing coordination of care and treatment with other providers

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.

Measures implemented in MIPS may be available for public reporting on Physician Compare.

Preference will be given to electronically specified measures (eCQMs)

eCQMs must meet EHR system infrastructure requirements, as defined by the future MIPS regulation.

The data collection mechanisms must be able to transmit and receive requirements as identified in future MIPS regulation. For example, eCQMs must meet QRDA standards.

Measures must be fully developed and tested.

Reliability and validity testing must be conducted for measures.

Feasibility testing must be conducted for eCQMs.

Measures should not duplicate other measures currently in the MIPS. Duplicative measures are assessed to see which would be the better measure for the MIPS measure set.

Measure performance and evidence should identify opportunities for improvement. CMS does not intend to implement measures in which evidence identifies high levels of performance with little variation or opportunity for improvement, e.g. measures that are “topped out.”

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

A sub-set of 3 DM and 1 CAD Web Interface measures.

Diabetes: High Blood Pressure Control

Diabetes: Hemoglobin A1c Control (<8%)

Diabetes: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease

Coronary Artery Disease (CAD): ACE-I/ARB Therapy – Diabetes or LVSD

2013 CAHPS for ACOs measures

4 CAHPS for ACOs summary survey measures.

Getting timely care, appointments, and information

How well providers Communicate

Patient’s Rating of Provider

Health Promotion & Education

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.

Outcome measures

Composite measures

Risk adjusted 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:

As statutorily mandated, quality measures must be statistically valid and reliable, and risk adjustment should be considered for outcome measures as appropriate.

They must be readily comprehensible to users so that users can leverage the performance information to inform their health care decisions.

They should enable users to make meaningful and valid comparisons of performance results across health care professionals and group practices by having the following properties:

There should be sufficient variation in the performance rates, since comparisons would be difficult if the majority of providers are clustered at one or two performance rates.

There should be room for improvement in the measure performance.

There should be a sufficient number of cases in the measure denominator, since performance rates that are based only on a handful of cases may result in unreliable rates and make statistically valid comparisons difficult.

There should be a sufficient number of health care professionals or group practices in each peer group comparison.

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

General comments

Merit-Based Incentive Payment System (MIPS)

30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (No public comments received; MUC ID: MUC15-402)
Acquired Involutional Entropion: Normalized lid position after surgical repair (No public comments received; MUC ID: MUC15-377)
Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Public comments received:5; MUC ID: MUC15-396)
Acute Anterior Uveitis: Post-treatment visual acuity (Public comments received:4; MUC ID: MUC15-394)
Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-412)
Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Public comments received:4; MUC ID: MUC15-399)
Chronic Anterior Uveitis: Post-treatment visual acuity (Public comments received:4; MUC ID: MUC15-397)
Common femoral arterial access site complication (No public comments received; MUC ID: MUC15-424)
Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Public comments received:4; MUC ID: MUC15-461)
Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Public comments received:5; MUC ID: MUC15-370)
Diabetic Macular Edema: Loss of Visual Acuity (Public comments received:2; MUC ID: MUC15-393)
Documentation of offering a trial of conservative management prior to fecal incontinence surgery (No public comments received; MUC ID: MUC15-440)
Documentation of offering a trial of conservative management prior to urgency incontinence surgery (No public comments received; MUC ID: MUC15-441)
Efficacy of uterine artery embolization for symptomatic uterine fibroids (No public comments received; MUC ID: MUC15-423)
Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Public comments received:1; MUC ID: MUC15-379)
Glaucoma - Intraocular Pressure (IOP) Reduction (Public comments received:42; MUC ID: MUC15-372)
Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Public comments received:3; MUC ID: MUC15-374)
Hepatitis A vaccination for patients with cirrhosis (No public comments received; MUC ID: MUC15-210)
Hepatitis B vaccination for patients with chronic Hepatitis C (Public comments received:3; MUC ID: MUC15-220)
Hepatitis B vaccination for patients with cirrhosis (No public comments received; MUC ID: MUC15-211)
Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Public comments received:2; MUC ID: MUC15-229)
HIV Screening for Patients with Sexually Transmitted Disease (STD) (No public comments received; MUC ID: MUC15-230)
Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-413)
Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (Public comments received:6; MUC ID: MUC15-450)
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (No public comments received; MUC ID: MUC15-275)
Minimally invasive surgery performed for patients with endometrial cancer (Public comments received:1; MUC ID: MUC15-452)
New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (No public comments received; MUC ID: MUC15-296)
NMSC: Biopsy Reporting Time - Pathologist (Public comments received:1; MUC ID: MUC15-216)
Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Public comments received:1; MUC ID: MUC15-392)
Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Public comments received:6; MUC ID: MUC15-215)
Non-Recommended PSA-Based Screening (Public comments received:1; MUC ID: MUC15-1019)
Non-selective beta blocker use in patients with esophageal varices (Public comments received:5; MUC ID: MUC15-209)
Over-utilization of mesh in the posterior compartment (No public comments received; MUC ID: MUC15-436)
Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (No public comments received; MUC ID: MUC15-928)
Patient reported outcomes following ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-411)
Patient-Reported Functional Communication (No public comments received; MUC ID: MUC15-313)
Performance of objective measure of functional hearing status (No public comments received; MUC ID: MUC15-307)
Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Public comments received:4; MUC ID: MUC15-465)
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 (Public comments received:4; MUC ID: MUC15-454)
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. (Public comments received:4; MUC ID: MUC15-466)
Potential Opioid Overuse (No public comments received; MUC ID: MUC15-1169)
PQI 91 Prevention Quality Acute Composite (No public comments received; MUC ID: MUC15-577)
Prevention Quality Indicators 92 Prevention Quality Chronic Composite (No public comments received; MUC ID: MUC15-576)
Proportion admitted to hospice for less than 3 days (Public comments received:4; MUC ID: MUC15-415)
Rate of adequate percutaneous image-guided biopsy (No public comments received; MUC ID: MUC15-420)
Route of hysterectomy (No public comments received; MUC ID: MUC15-437)
Screening endoscopy for varices in patients with cirrhosis (No public comments received; MUC ID: MUC15-251)
Screening for Hepatoma in patients with Chronic Hepatitis B (No public comments received; MUC ID: MUC15-217)
Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Public comments received:2; MUC ID: MUC15-375)
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) (No public comments received; MUC ID: MUC15-459)
Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Public comments received:2; MUC ID: MUC15-212)
Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Public comments received:4; MUC ID: MUC15-221)
Surveillance endoscopy for dysplasia in Barrett's Esophagus (Public comments received:2; MUC ID: MUC15-208)
Testing for uterine disease prior to obliterative procedures (No public comments received; MUC ID: MUC15-439)
Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Public comments received:1; MUC ID: MUC15-460)
Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Public comments received:4; MUC ID: MUC15-463)
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 (Public comments received:3; MUC ID: MUC15-179)
Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Public comments received:1; MUC ID: MUC15-178)
Use Of Preventive Screening Protocol For Transplant Patients (Public comments received:4; MUC ID: MUC15-177)
Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (No public comments received; MUC ID: MUC15-434)

Medicare Shared Savings Program

Advance Care Plan (No public comments received; MUC ID: MUC15-578)
Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (No public comments received; MUC ID: MUC15-579)
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (No public comments received; MUC ID: MUC15-275)
PQI 91 Prevention Quality Acute Composite (No public comments received; MUC ID: MUC15-577)
Prevention Quality Indicators 92 Prevention Quality Chronic Composite (No public comments received; MUC ID: MUC15-576)

Physician Compare

30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (No public comments received; MUC ID: MUC15-402)
Acquired Involutional Entropion: Normalized lid position after surgical repair (No public comments received; MUC ID: MUC15-377)
Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (No public comments received; MUC ID: MUC15-396)
Acute Anterior Uveitis: Post-treatment visual acuity (No public comments received; MUC ID: MUC15-394)
Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-412)
Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (No public comments received; MUC ID: MUC15-399)
Chronic Anterior Uveitis: Post-treatment visual acuity (No public comments received; MUC ID: MUC15-397)
Common femoral arterial access site complication (No public comments received; MUC ID: MUC15-424)
Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (No public comments received; MUC ID: MUC15-461)
Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (No public comments received; MUC ID: MUC15-370)
Diabetic Macular Edema: Loss of Visual Acuity (No public comments received; MUC ID: MUC15-393)
Documentation of offering a trial of conservative management prior to fecal incontinence surgery (No public comments received; MUC ID: MUC15-440)
Documentation of offering a trial of conservative management prior to urgency incontinence surgery (No public comments received; MUC ID: MUC15-441)
Efficacy of uterine artery embolization for symptomatic uterine fibroids (No public comments received; MUC ID: MUC15-423)
Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (No public comments received; MUC ID: MUC15-379)
Glaucoma - Intraocular Pressure (IOP) Reduction (No public comments received; MUC ID: MUC15-372)
Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (No public comments received; MUC ID: MUC15-374)
Hepatitis A vaccination for patients with cirrhosis (No public comments received; MUC ID: MUC15-210)
Hepatitis B vaccination for patients with chronic Hepatitis C (No public comments received; MUC ID: MUC15-220)
Hepatitis B vaccination for patients with cirrhosis (No public comments received; MUC ID: MUC15-211)
Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (No public comments received; MUC ID: MUC15-229)
HIV Screening for Patients with Sexually Transmitted Disease (STD) (No public comments received; MUC ID: MUC15-230)
Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-413)
Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (No public comments received; MUC ID: MUC15-450)
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (No public comments received; MUC ID: MUC15-275)
Minimally invasive surgery performed for patients with endometrial cancer (No public comments received; MUC ID: MUC15-452)
New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (No public comments received; MUC ID: MUC15-296)
NMSC: Biopsy Reporting Time - Pathologist (No public comments received; MUC ID: MUC15-216)
Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (No public comments received; MUC ID: MUC15-392)
Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (No public comments received; MUC ID: MUC15-215)
Non-Recommended PSA-Based Screening (Public comments received:5; MUC ID: MUC15-1019)
Non-selective beta blocker use in patients with esophageal varices (No public comments received; MUC ID: MUC15-209)
Over-utilization of mesh in the posterior compartment (No public comments received; MUC ID: MUC15-436)
Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (No public comments received; MUC ID: MUC15-928)
Patient reported outcomes following ilio-femoral venous stenting (No public comments received; MUC ID: MUC15-411)
Patient-Reported Functional Communication (No public comments received; MUC ID: MUC15-313)
Performance of objective measure of functional hearing status (No public comments received; MUC ID: MUC15-307)
Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (No public comments received; MUC ID: MUC15-465)
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 (No public comments received; MUC ID: MUC15-454)
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. (No public comments received; MUC ID: MUC15-466)
Potential Opioid Overuse (No public comments received; MUC ID: MUC15-1169)
PQI 91 Prevention Quality Acute Composite (No public comments received; MUC ID: MUC15-577)
Prevention Quality Indicators 92 Prevention Quality Chronic Composite (No public comments received; MUC ID: MUC15-576)
Proportion admitted to hospice for less than 3 days (No public comments received; MUC ID: MUC15-415)
Rate of adequate percutaneous image-guided biopsy (No public comments received; MUC ID: MUC15-420)
Route of hysterectomy (No public comments received; MUC ID: MUC15-437)
Screening endoscopy for varices in patients with cirrhosis (No public comments received; MUC ID: MUC15-251)
Screening for Hepatoma in patients with Chronic Hepatitis B (No public comments received; MUC ID: MUC15-217)
Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (No public comments received; MUC ID: MUC15-375)
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) (No public comments received; MUC ID: MUC15-459)
Surveillance colonoscopy for dysplasia in colonic Crohns Disease (No public comments received; MUC ID: MUC15-212)
Surveillance colonoscopy for dysplasia in Ulcerative Colitis (No public comments received; MUC ID: MUC15-221)
Surveillance endoscopy for dysplasia in Barrett's Esophagus (No public comments received; MUC ID: MUC15-208)
Testing for uterine disease prior to obliterative procedures (No public comments received; MUC ID: MUC15-439)
Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (No public comments received; MUC ID: MUC15-460)
Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (No public comments received; MUC ID: MUC15-463)
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 (No public comments received; MUC ID: MUC15-179)
Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (No public comments received; MUC ID: MUC15-178)
Use Of Preventive Screening Protocol For Transplant Patients (No public comments received; MUC ID: MUC15-177)
Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (No public comments received; MUC ID: MUC15-434)

Full Comments (Listed by Measure)

General

The AAFP urges the MAP to be aware and cognizant of the efforts of the multi-stakeholder Core Quality Measures Collaborative while reviewing measures for inclusion for federal programs. This effort works to ensure alignment, harmonization, and the avoidance of competing quality measures among payers. These sets contain a variety of measure types targeting both resource use, quality, and patient satisfaction. The AAFP has a general concern that many of these measures are currently under development, or are in field testing. Because of this, there is no clear way of knowing if they will measure what they intend to measure, or if there are unintended consequence that have yet been uncovered. We propose to include only fully develop measured in this year’s rule making. (Submitted by: American Academy of Family Physicians )
On behalf of Adventist Health System (AHS), I wish to provide the following overall comments. The timeframe of this comment opportunity is too short to provide substantive comments about the potential of these Measures under Consideration to add value, improve outcomes, create undue data collection burden or access whether a better measure exists. We urge the Measure Applications Partnership (MAP) to ensure that the measures that the Centers for Medicare and Medicaid Services (CMS) is considering for use in federal programs are fully developed, tested and vetted to ensure reliability and validity. We believe that the National Quality Forum (NQF) should not offer support or even “conditional” support for any measures that have not received NQF endorsement. In addition, the MAP should assess all Measures under Consideration for alignment with measures currently in use in federal programs. This assessment should ensure that measures are unique and well-correlated with outcomes that are meaningful to patients. Priority should be given to the most valid, reliable and meaningful measures. Any recommendation for a new measure that competes with a measure currently in use in a federal program should include a condition that the competing measure be removed from the federal program or a condition that the two measures be harmonized prior to the adoption of the new measure. (Submitted by: Adventist Health System)
Thank you for the opportunity to review and provide comment on the Measures Under Consideration. The AAN continues to have a concern over the lack of neurology specific measures available through the different CMS programs especially given the growing population of aging adults. With the prevalence of chronic neurologic disease continuing to grow in the aging population and the relative number of available neurologists decreasing we must do something to assist treating physicians participate in applicable programs. The AAN believes that expanding the list of measures to be more inclusive of specialties will only serve to benefit of populations with neurological needs. (Submitted by: American Academy of Neurology)

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

The proposed “Non-Recommended PSA-Based Screening” measure discourages PSA screening in all men over age 18, regardless of age or risk factors. The proposed measure could potentially be used in all of Medicare’s quality reporting programs, which would financially penalize physicians or other providers who order a PSA screening test. The measure is based on the flawed PSA screening recommendation of the U.S. Preventive Services Task Force and contradicts practice guidance by the AUA, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American College of Physicians-American Society of Internal Medicine and the American Cancer Society. (Submitted by: Kansas City Urology Care)
Dear CMMS: I am a recent graduate of the Fox Chase Cancer Center Urologic Oncology Fellowship program. As a surgeon who did extra training in order to understand the unique challenges and opportunities to improve cancer of urological cancer patients, and as someone who regularly sees prostate cancer patients, I strongly disagree with this proposed measure. By penalizing physicians for PSA screening patients, this measure will in essence take revoke the right of patients to make informed decisions about their care. While I believe that overdiagnosis and overtreatment have been a problem in the past, there is clear evidence that those trends are being reversed as primary care providers and urologists in particular become more educated about prostate cancer treatment in the context of at-risk populations. It is unfair to penalize future patients for the overtreatment of past patients; cancer care specialists were treating the disease based on the best available information at the time, prior to an era when anyone knew that active surveillance was an option for patients with low risk disease. In the absence of knowledge about what to do, those physicians were trying to make the best decisions for their patients. Now that we have a deeper understanding of the natural history of low risk prostate cancer, physicians are again making the best decisions they can based on the information at hand, including active surveillance and/or watchful waiting of these indolent tumors. However, by recommending against prostate cancer screening, the CMMS will blind physicians to potentially curable diseases by censoring information. Yes, I view the penalization for gathering information about a patient's prostate cancer risk as censorship. It is also profoundly un-American to exempt the patient's right to choose to be screened after an informed discussion of the risks, benefits, and alternatives. I hope that the CMS and other parties germane to this discussion are able to come to an equitable and fair compromise regarding the right of patients and caregivers to screen for prostate cancer. I am happy to discuss this further by email or by telephone. Sincerely, Philip Abbosh MD-PhD philip.abbosh@fccc.edu 812-320-1880 (Submitted by: Fox Chase Cancer Center)
I think this is too general. I believe that in some circumstances men should be offered PSA testing and that in the age range 55-69 men should be given the educated option to test or not. High risk men need to be identified and given this option as well. (Submitted by: CIty of Hope)
I am a 77 yo male in good health. Over 30 years ago, I was found to have an elevated PSA. I underwent a transurethral ultrasound and biopsy of my prostate which was negative for prostate cancer. My PSA was monitored biannually, and 1 year later was noted to increase slightly. Another TRUSP and biopsy was negative except for 1 small focus of cancer which was so small, that the pathologist was unable to even grade it (Gleason). I was placed on Avodart, and continued biannual PSA's. Over the next 30 years, periodic elevations in my PSA required repeat biopsies all of which were negate except for one done this year which showed an area of Gleason 4+3=7 prostate cancer. My urologist recommended external beam IMRT radiation therapy for which I received 44sessions without problems. I agreed with everything my urologists in Texas and Florida recommended over the 30 plus years my PSA was elevated, for you see, I am a Board Certified urologist myself. We now have another tool - MRI Prostate Imaging which may have confirmed a diagnosis of prostate cancer earlier in my case. The PSA is a very valuable tool for urologists used to both diagnose and follow the course of the disease post treatment. (Submitted by: AUA)
To Whom It May Concern: As a urologic oncologist and health services researcher, I welcome the opportunity to review and provide comments on the Non-recommended PSA- Based Screening Measure under Consideration. I believe that the proposed measure will lead to a number of unintended consequences, the most egregious of which is a significant step away from individualized, patient-centered care and shared decision-making. Shared decision-making between the patient and provider for prostate cancer screening with a PSA test is unanimously supported by the American Urological Association, the American Cancer Society, the American College of Physicians, the American Society of Clinical Oncology and the National Comprehensive Cancer Network. The proposed measure will effectively eliminate the patient from the decision to obtain PSA screening by penalizing physicians who provide this service. Beyond completely disregarding individual patient preferences, the proposed measure provides no consideration for the patients who benefit the most from PSA screening, including those with a family history or a racial predilection to high-risk prostate cancer. While the role of PSA screening in the general population remains debated, denying men who are predisposed to high-risk the opportunity to screen for this lethal disease is not acceptable. Specifically, this measure is neither useful nor appropriate for assessing the quality of care for Medicare beneficiaries, as most would agree that high quality care must consider patient preferences. Our current models of prostate cancer care support patient autonomy, discussions of risks and benefits and shared decision making between patients, families and their providers. Clearly, this measure will undermine these efforts and I urge you to reconsider its adoption. Sincerely, Lindsey A. Herrel, MD MS (Submitted by: Urology)
I think this does a great injustice to men in allowing them to make an informed decision regarding PSA testing. Just as everyone agrees that 'blanket' PSA testing at fairs, etc is not an effective strategy; blanketing it a 'bad' idea, universally is also highly problematic. At the end of the day, the diagnosis and treatment of prostate cancer is about weighing risks and benefits--it is about managing risk. To decide for men that they don't have a choice in being diagnosed and treated for a potentially life-threatening cancer--even if it means the unlikely side effects of incontinence or impotence is paternalistic. It would not surprise me if twenty years down the road or so, when the natural history of untreated and metastatic prostate cancer plays out if we look at this measure (and at the USPSTF task force recommendation) as one of the modern day blunders in contemporary medicine, akin to estrogen replacement therapy in women. (Submitted by: Memorial Sloan Kettering)
As you know, discussion about the risks and benefits of PSA screening, in targeted populations, is advocated by many leading societies, including the American College of Physicians, the American Society of Clinical Oncology, the American Cancer Society, the National Comprehensive Cancer Network and the American Urological Association. The American College of Physicians recommends discussion about risks and benefits of PSA screening in men between the age of 50 and 69 years. The American Society of Clinical Oncology recommends discussion about risks and benefits of PSA screening in men with a life expectancy > 10 years. The American Cancer Society recommends discussion about risks and benefits of PSA screening in men: over the age of 50 years for men who are at average risk of prostate cancer and are expected to live at least 10 more years, over the age of 45 years for African Americans and men who have one first-degree relative diagnosed with prostate cancer at an age younger than 65 years, and over the age of 40 years for men with more than one first-degree relative diagnosed with prostate cancer at an age younger than 65 years. The National Comprehensive Cancer Network recommends discussion about risks and benefits of PSA screening in men over the age of 45 years. Finally, the American Urological Association recommends discussion about risks and benefits of PSA screening in men between the age of 55 and 69 years, and in men 40 to 54 years who are African-American or have family history of prostate cancer. Clearly there is substantial disagreement about the role of PSA-screening. At the very least, a national clinical quality measure should not be deeply divisive and controversial, as this PSA screening measure would be. The measure, as currently drafted, recognizes the shortcomings of routine PSA screening without consideration of age/comorbidities, individualized risk for prostate cancer and patient preferences. Additionally, it is based on a the current recommendation of the United States Preventive Services Task Force (USPSTF) and a HEDIS measure that only focuses on PSA-based screening in men 70 years and older. As you know, the USPSTF is now in the process of updating this specific recommendation (currently in the phase of public comment about research methodology). Therefore, I urge CMS to delay further development of this measure until the task force has reviewed the literature, analyzed the evidence, and completed its update process. The proposed measure does not provide exclusions for men at high risk, including African Americans and those with a family history. This is a critical patient population which many medical societies specifically state should be considered distinct from the broader population. (Submitted by: University of Michigan Dept of Urology)
To whom it may concern, Non reimbursement of PSA screening would represent a considerable step backward in the diagnosis and treatment of prostate cancer in the United States. Please note the following: 1, While the death rate from prostate cancer has decreased somewhat since PSA screening was introduced in the late 1980's, the total population of the U.S. has increased significantly, Because of an aging population, the population at risk from prostate cancer has actually increased even more, resulting in a significant decrease in prostate cancer mortality over this time period. 2. There is no commercially available test which could at the present time replace PSA. 3. This decision would disproportionately affect older men, and would represent gender and age-related discrimination. 4. Studies that were available to U.S. Preventive Services Task Force when their recommendation for non-screening was made, contradict their estimation of over treatment. 5. Their recommendation of non screening has not been adopted by other developed countries or US-based healthcare agencies. Sincerely, Gary H. Carl, MD Olean General Hospital 623 Main St.. Ste 200 Olean, New York, 14760 (Submitted by: Olean General Hospital)
A measure against PSA screening would have drastic public health implications for American men. There are numerous studies that prove that intelligent use of PSA as a screening tool decreases prostate cancer mortality in appropriate candidates. While we can all agree that not all men should be screened, there are clearly a subset of men who will benefit from PSA screening. Certainly we need to focus on screening more intelligently, but eliminating PSA screening all together will certainly increase rates of metastatic prostate cancer and prostate cancer mortality. Enacting a measure that will increase a man's risk of dying of prostate cancer would be a terrible, and entirely avoidable, mistake. (Submitted by: Temple University School of Medicine)
I write this note with great concern regarding PSA screening. PSA is the mainstay marker for diagnosis and management of prostate cancer. The USPSTF recommendation of not using PSA for screening is irresponsible and illogical. There is no widely accepted test other than PSA that is economical and efficient in detecting prostate cancer. If we don't screen for harmful prostate cancer, it will cost the society in the long run even more by having to take care of late stage cancer patients, not to mention the side effects and overall survival decrease that will happen as well. This ruling goes against logic and all guidelines of AUA, SUO, etc. I would recommend to consult with the experts and then make a final decision regarding better Prostate cancer screening. Sincerely, Saumil Karavadia, MD (Submitted by: Advanced Urology)
To whom it may concern, Thank you for considering my comments on the proposed MUC15-1019 - Non-Recommended PSA-Based Screening. As a practicing general urologist, I see this issue as one of the utmost importance to the future of men's health and cancer care in the United States. The USPSTF decision to change the rating of PSA as a screening test was deeply disturbing, and based on flawed and incomplete data. Of the two trials used to arrive at the decision, one was flawed in its methods, allowing up to 50% of men in the non-screening arm to undergo screening. The other trial, which did have a better design, eventually showed a survival benefit to screening in data published within 1 year after the data used by the task force. An additional limitation of both studies was the single focus on mortality, and the disregard for morbidity of metastatic prostate cancer, which is significant. It is well known, based on retrospective data, that implementation of PSA screening in this country has led to a 50% reduction in prostate cancer mortality. In addition, we have seen the proportion of prostate cancer that was metastatic at diagnosis drop by 80% since PSA screening has become widespread. Please consider these facts when deciding on the proposed regulation. Also consider the lives of all the fathers, brothers, and sons who will be deprived of proper cancer prevention, and will be forced to return to an era when the only treatment options were palliative care and comfort measures. (Submitted by: American Urologic Association)
The suggestion that using the ordering of PSA as a negative quality point represents a step backward in the identification of prostatic cancer. The overwhelming number of prostate cancers are identified by following up on an elevated PSA. Prostate cancer is not characterized by any specific symptoms and these symptoms or physical changes are late stage developments. The thought that a physician would have to choose between doing what is the possibility a life saving test or avoiding a neg quality indicator for the doctor is totally inappropriate. The government has not made its case to the public or the profession and until it does it would be inappropriate to incorporate this quality indicator. (Submitted by: Urology Associates, Nashville Tn)
Blanket recommendations to avoid PSA screening are likely based on the USPSTF's inherently flawed recommendations. The control arm of the PLCO trial cited by the the task force was heavily contaminated with PSA screened patients. PLCO is therefore a trial of "some screening" vs "more screening." It is therefore understandable that the PLCO trial did not show a benefit to PSA screening. The ESRPC study (European) had very little PSA screening in the control arm, and shows a clear cancer specific survival benefit to PSA screening. Subsequent longer term followup of ESRPC continues to show an even larger benefit as longer term data becomes available. Intelligent use of PSA screening coupled with appropriate use of treatment (including active surveillance in appropriate patients) is a clear benefit to our patients. Every man deserves a thoughtful discussion with his physician about the risks and benefits of screening for the second leading cause of cancer death in men. Penalizing his physician (and ultimately the patient) for screening will ultimately put us on the wrong side of history (and the wrong side of good medical science). (Submitted by: Canton Urology Associates)
I am very much in favor of efforts to reduce the harm associated with PSA testing. But reducing PSA screening for all men is a very blunt instrument. I am against the proposed measure for two reasons. First, quality measures that attempt to restrict access to an intervention should be restricted to areas where there is a broad consensus that the intervention does more harm than good. There is no such consensus with respect to PSA screening. The US PLCO trial was grossly contaminated, with about half of patients in the control group undergoing PSA testing. The authors of the PLCO trial describe the trial not as a trial of screening vs. no screening but “opportunistic vs. systematic screening”. Hence there is one major randomized trial, ERSPC, that compared screening to no screening (Lancet. 2014 Dec 6;384(9959):2027-35). This found a mortality benefit to screening. A major modeling study has demonstrated that screening leads to improvements in quality adjusted life years (N Engl J Med. 2012 Aug 16;367(7):595-605. doi: 10.1056/NEJMoa1201637). It is extremely problematic to restrict access to an intervention that is clearly favored by the major studies of that intervention. Many of us would be prepared to listen to arguments that PSA screening does indeed do more harm than good. That is not the point, however: unless there is an academic consensus an issue, it should not be a quality measure. My second objection to the proposed quality measure is that there are much more effective ways to achieve the desired ends of reducing harm from PSA screening. The most obvious point is that the majority of the harms from screening come from overtreatment, not overdiagnosis. There is good evidence from a randomized trial (N Engl J Med. 2012 Jul 19;367(3):203-13. doi: 10.1056/NEJMoa1113162), and considerable consensus in the academic community, that treatment does not benefit patients with low risk disease. Treatment of low risk prostate cancer is therefore an obvious candidate for a quality metric, indeed, it is one metric used to evaluate surgeons at Memorial Sloan-Kettering Cancer Center. Another alternative to the proposed quality metric is to a more nuanced approach to reduced PSA testing. The ERSPC trial did not find benefit to screening in men over 70, and the modeling study referenced above found that any mortality benefits from screening men in their 70’s is offset by reductions in quality of life. My own group has demonstrated that 42% of overdiagnosed cases occur in men over 70 and nearly 70% of overdiagnosed cases occur in men over the age of 65 (BMC Med. 2014 Feb 11;12:26. doi: 10.1186/1741-7015-12-26). Hence restricting screening only in older men would dramatically reduce overtreatment without a consequent impact on any benefits of PSA screening. In sum, I agree that reduce harms from PSA screening should be an urgent priority. Reducing PSA screening across the board is not the best way to achieve this aim. (Submitted by: Memorial Sloan Kettering Cancer Center)
I have many concerns regarding the flawed interpretation of PSA screening by the USPSTF in the PLCO and an almost complete disregard of the ERSPC trial which showed the advantage of PSA screening. My concerns echo that of LUGPA and AUA letters which have already been submitted. However, the greater concern is that CMS now proposes to provide a financial incentive for physicians to NOT have an informed discussion with their patients about the risks and benefits of prostate cancer screening. Prostate cancer is the number one cause of non-skin cancer in men and the second leading cause of death from cancer in men. CMS now proposes a financial incentive to NOT screen men for the second leading cause of cancer death? In addition to taking the decision about health related issues out of the hands of the involved stakeholders (patient and physician), the proposed policy is directly against the recommendations of the 2 groups that actually care for the men with prostate cancer (AUA and ACS). I am almost at a loss for words due to the shocking nature of this proposal. (Submitted by: Urology Clinics of North Texas)
This is simply a mistake. The USPSTF recommendations were flawed, and one cannot make recommendations when the base building blocks are incorrect. Please, for the sake of our patients, consider abolishing this until years of properly performed research can be completed. We physicians use our years of training and experience in dealing with our patients, you should let us practice medicine for the benefit of the patient. (Submitted by: Rocky Mount Urology Associates)
While PSA as a screening measure has limitations, it remains the best available screening test for the most common cancer among men. Discouraging testing, while seemingly financially attractive for the healthcare system at large, will lead to the scenario of aggressive and potentially lethal cancers being missed. Turning a blind eye to a cancer that kills 1 in 38 men is not quality care. I support the current PSA screening guidelines of the American Urological Association where screening is focused on shared decision making and assessment of risk. I do not believe that a financial incentive has any place in that conversation. (Submitted by: Aultman Hospital)
The proposed “Non-Recommended PSA-Based Screening” measure discourages PSA screening in all men over age 18, regardless of age or risk factors. The proposed measure could potentially be used in all of Medicare’s quality reporting programs, which would financially penalize physicians or other providers who order a PSA screening test. The measure is based on the flawed PSA screening recommendation of the U.S. Preventive Services Task Force and contradicts practice guidance by the AUA, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American College of Physicians-American Society of Internal Medicine and the American Cancer Society. (Submitted by: Kansas City Urology Care)
On behalf of the physicians of Urology Specialists Clinic and Surgical, we are strongly opposed to this proposed measure. In the United States, the rate of dying from prostate cancer has decreased by 40% and the rate of developing metastatic prostate cancer has decreased by 75% since the introduction of PSA testing 25 years ago. This disease is curable if caught early, but shows no symptoms until it has spread. Therefore, PSA is still really the only tool we have to detect the cancer before it is too late to cure. We continue to believe that PSA screening is valuable, saves lives, and it is the right of each patient to have a conversation with their physician about potential benefits as well as harms and decide whether PSA screening is right for them. The proposed "Non-Recommended PSA-Based Screening" measure discourages PSA screening in all men over age 18, regardless of age or risk factors. The proposed measure could potentially be used in all of Medicare's quality reporting programs, which would financially penalize providers who order a PSA screening test. The measure is based on the flawed PSA screening recommendations of the U.S. Preventive Services Task Force and contradicts practice guidance issued by the AUA, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American College of Physicians-American Society of Internal Medicine and the American Cancer Society. (Submitted by: Urology Specialists Chartered)
PSA is the best screening tool at this time for proper diagnosis and treatment of prostate cancer. Until a better test becomes available, we should not pretend that prostate cancer does not exist. PCA s still the most commonly diagnosed solid organ cancer in men, and the second leading cause of cancer death in men. PSA screening, when done properly, has shown to decrease mortality from PCA. Not using PSA to screen men for PCA will harm men, and is not in the best interest of our patients. Instead of focusing on PSA screening, we should focus on proper treatment of PCA, and proper selection of who needs to be treated. Currently, there are a number of prognostic tests such as the 4K score, Prolaris Genetic Marker test, Oncotype Dx, and others that help clinicians risk stratify patients newly diagnosed with prostate cancer, and these tests can help direct proper selection of those who need to be treated. (Submitted by: Advanced Urology)
Most primary care physicians are ignorant about the nuances of screening, diagnosis, and treatment of prostate cancer. Thus, they refer appropriate patient to urologists. Unfortunately, since they are the gatekeepers to the specialists, measures like MUC15 disincentive primary care physicians to refer appropriate patients to urologists, who are knowledgeable in such aspects related to prostate cancer. Before and since the USPSTF recommendations against PSA screening, I have seen numerous black men under the age of 55 with PSA values in the 50 to 100 range. Such high risk individuals will die in the future if PSA screening and prostate cancer management is taken out of the hands of those who know it best, the urologists. (Submitted by: U of Florida College of Medicine, Jacksonville)
I am a practicing urologist. I strongly oppose any measure which would penalize physicians for ordering PSA tests. No matter what the details of the proposal are, the message to primary care providers would be interpreted simply as "If I a order PSA, I will pay a penalty." This measure would indeed have a chilling effect on PSA testing among those who are really at the front line of screening, primary care providers. Urologists are all too aware that the USPSTF recommendations are based on fundamentally flawed data, and as such have not stopped appropriate PSA screening. We have, however, made massive changes in the way we treat prostate cancer, with rapid adoption of active surveillance as a primary option for many men. Improvements in treatment of the primary tumor and better understanding of the natural history of the disease, however, mean nothing to men who are diagnosed with metastatic disease. These are the men who will pay the price for the discontinuation of PSA screening by primary care providers. On October 29. 2015, Gilbert Welch, MD MPH authored a piece in the NEJM which shows that since the initiation of widespread PSA screening in 1990, the incidence of new presentations of metastatic prostate cancer has dropped from around 65 per 100,000 to around 25. Unfortunately, there has been no comparable decrease in the incidence of metastatic breast cancer since the institution of widespread mammography. In addition, a quick look to the SEER database website on prostate cancer shows a more than 50% drop in the incidence of death from prostate cancer in the US since 1990. To stop PSA screening, we would give up these incredible gains we have made against prostate cancer. This change would be tantamount to stopping our anti-smoking campaign, which has brought similar massive improvements in the fight against lung cancer. If CMS would like to improve the lives of men at risk for prostate cancer, I would suggest that the agency focus on ensuring that men diagnosed with cancer are properly counseled and that those who would benefit from active surveillance are offered it. By doing so, treating physicians can help improve quality of life without sacrificing the amazing gains that PSA screening has produced in the last 25 years. (Submitted by: Virginia Urology)
I am Associate Professor of Urology, and of Epidemiology and Biostatistics, at the UCSF Helen Diller Family Comprehensive Cancer. I have published over 200 peer-reviewed peer reviewed articles, focused primarily on prostate cancer (http://www.ncbi.nlm.nih.gov/pubmed/?term=cooperberg+m). Much of my work and that of my colleagues at UCSF over the past 15 years has focused on problems of over-treatment of low-risk prostate cancer, and the resulting impacts of that over-treatment on affected men's quality of life. I have reviewed the USPSTF evidence summary and position in statement in detail and have met 4 of the task force members over the years. There is really no argument among anyone with true expertise on this question that the USPSTF reached the wrong conclusion with their "D" recommendation against screening. By regulation, the panel excludes specialists, but they chose to reject many key opinions by both clinical and statistical content experts, including the NIH/NCI-sponsored CISNET researchers. As a result, their evidence review was based on a fundamentally flawed interpretation of the existing evidence base. As just a few examples: • The PLCO trial, by the trial authors' own statement, was not a trial of screening vs. no screening; it was a trial of annual screening vs. opportunistic screening.(http://dx.doi.org/10.1093/jnci/djr500) It therefore should not have been included as evidence against screening. • The USPSTF statement re: absence of benefit at 8-10 years follows indicates a poor understanding of the intent of screening. The benefits only start to accrue at 8 years and take much longer to be fully realized (http://dx.doi.org/10.1200/JCO.2010.30.6373). A man with an 8-10 life expectancy should not be screened, and this is not controversial. • The USPSTF drastically over-states the harms of screening by cherry-picking the literature to find worst-case scenarios re: harms of treatment. E.g., they cite a 0.5% perioperative mortality rate for prostatectomy, based on out-dated papers reporting data from low-volume surgeons treating only older men. They ignored, e.g., a JAMA study showing a 10-fold lower rate in contemporary practice (http://dx.doi.org/10.1001/jama.2009.1451). • The USPSTF completely ignored risk factors like race and family history. African-American men are completely under-represented in all available data sources on screening, and are known to have much higher rates of prostate cancer and lethal prostate cancer. There are many, many other examples. The USPSTF is the only major guideline recommending against all screening. Most others, including the NCCN, AUA, ACS, and ACP/ASIM, recommend some variation on shared decision-making recognizing both benefits and harms of screening. There is no question that PSA screening has not been implemented optimally in the U.S.—we tend to start screening too late, we repeat screening too frequently, we continue too late among men with comorbidity, and we often overtreat low-risk disease and undertreat high-risk disease. The solution, however, is not to abandon screening but rather to screen smarter. Men with good life expectancy should be screened early, and, if the baseline is low, much less frequently. Low-risk disease should rarely be treated, and recent evidence shows that rates of active surveillance are rising very rapidly (http://dx.doi.org/10.1001/jama.2015.6036). But high-risk disease needs to be found early and treated aggressively. Screening and better treatment explain =60% of the over 50% drop in prostate cancer mortality rates we have seen since the 1990s (http://dx.doi.org/10.1002/cncr.27594), and it is a mathematical certainty that if we abandon screening wholesale we will be return to the 1980s in terms of metastatic disease levels (http://dx.doi.org10.1002/cncr.28932), and given the aging population and new treatments available, this will equate to an extraordinary burden of entirely avoidable suffering, early mortality, and costs to the healthcare system. Early data following the 2012 "D" recommendation suggest that we have seen a 25% drop in overdiagnosis of low-risk disease—and a 25% drop in diagnosis of high-risk disease as well which implies a comparable increase in underdiagnosis. (http://dx.doi.org/10.1016/j.juro.2015.06.075). Final specific comments on the proposed CQM: 1) 4.0 is no longer recognized as a uniform threshold. A PSA above 4 for an older man with BPH may be unconcerning, but a PSA even above 1 for a healthy 50 year old would at least justify follow-up repeat retesting. 2) "Dysplasia" of the prostate is a nonspecific term that does not correspond to any current pathological diagnosis. 3) LUTS (voiding symptoms) and BPH are also absolute indications for PSA. In closing, to establish a CQM on this issue suggests that consensus exists where in fact a raging controversy continues. In fact, even the USPSTF will be re-addressing the question and has just opened public comment on their evidence plan. PSA screening should be improved not abandoned, and this CQM would be a major step in the wrong direction, and exactly the wrong time. Feel free to contact me at matthew.cooperberg@ucsf.edu for any clarifications or questions. (Submitted by: University of California, San Francisco)
As a urologist who treats prostate cancer patients, I do not support using PSA testing as a quality measure. The original grade D decision by the USTSPS was based on poor studies and the current risks/benefit ratio has tipped in favor of PSA screening as active surveillance of prostate cancer has become more utilized. Appropriate PSA testing based on shared decision making between the patient and the doctor should be recommended, and a physician should not be penalized if a mutual decision has been made to screen for prostate cancer, especially in high risk patients. (Submitted by: Mayo Clinic Arizona)
There is ample evidence to prove that PSA screening significantly improves survival in the treatment of prostate cancer. It is highly unfortunate that the USPTFA did not take this data into consideration or allow the input of National Urological Associations and Oncology associations. For any decision like this to be made, thought leaders in these fields need to reexamine this issue to formulate an appropriate decision. I feel that this is so wrong, that it would be justified to take legal action for male discrimination by CMS and get the Supreme Court involved as well as Congress to overturn this misguided decision. (Submitted by: AUA)
The PSA is a valuable tool for diagnosis and management of men who are at risk for prostate cancer. Improved interpretation of the test and counseling are more appropriate than attempts to penalize providers for ordering the test. Do not discourage counseling and communication between patient and physician. (Submitted by: J Szobota MD)
Patrick Conway, MD Deputy Administrator for Innovation & Quality Centers for Medicare & Medicaid Services Chief Medical Officer 7500 Security Boulevard Baltimore, MD 21244 Kate Goodrich, MD Director Quality Measurement and Value-Based Incentives Group Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Subject: MUC15-1019: Non-Recommended PSA-Based Screening December 7, 2015 Dear Drs. Conway and Goodrich, ZERO - The End of Prostate Cancer (ZERO) appreciates the opportunity to comment on the draft clinical quality measure MUC15-1019 the “Non-Recommended screening for prostate cancer using prostate-specific antigen (PSA): Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening.” ZERO is a national nonprofit with the mission of ending prostate cancer. We lead the fight to end the disease by advancing research, encouraging action, and providing education and support to men and their families. As you may know, prostate cancer is a disease that will impact one in seven American men in his lifetime. There are nearly 2.8 million men living in the United States with prostate cancer and the American Cancer Society estimates that in 2015 roughly 220,800 men will be diagnosed and 27,540 men will lose their lives to the disease. ZERO is very concerned the measure under consideration does not include basic exclusions recommended by a range of provider and advocacy groups or appropriately target the harmful overtreatment of men (instead focusing on over-screening). In addition, we are troubled that the release of the draft measure does not take into consideration the upcoming revision of the U.S. Preventive Services Task Force (USPSTF) recommendation. CMS’ call for comments asked for feedback in several specific areas, for those our comments are as follows. First, this draft measure is too broad in its population catchment to add significant value in assessing the quality of care for Medicare-aged beneficiaries. We recommend a more nuanced approach, making exclusions for age and other risk factors, which will allow CMS to accurately assess whether or not patients are encountering physicians who employ best practices in screening across the range of age groups in the Medicare population and accurately adjust for an individual patient’s demographic factors and medical history. Second, the measure could significantly harm patient outcomes. The absence of ordering a diagnostic blood test does not indicate quality provider performance or improve patient outcomes; quite the contrary. Instead it offers a perverse incentive for physicians to maintain ignorance of the condition, including associated new diagnoses or treatment options, and limit discussion, diagnosis and treatment for patients. The burden of reporting this measure is best commented on by provider. However, the promise of EHRs allows for a more accurate provider response, and thus a more detailed screening and treatment recommendation, reflecting best practices that National Headquarters 515 King Street • Suite 420 • Alexandria, VA 22314 take into consideration risk factors, individual life expectancy, and disease progression estimations. Finally, Zero is supportive of recommendations by many of the professional societies, provided in more detail below, all of which acknowledge the variations that exist in men of different ages and backgrounds. These recommendations are discussed in more detail below. ZERO’s broad concern with the proposed measure is that it further discourages the use of medically necessary PSA screening in all men over age 18, regardless of age or risk factors, setting up a scenario whereby physicians could be financially penalized for diagnosing a fatal cancer in men who, with treatment, would not die of the disease. The measure is based on the flawed PSA screening recommendations of the USPSTF and contradicts practice guidance issued by the American Urological Association, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American College of Physicians-American Society of Internal Medicine, and the American Cancer Society. The measure, as currently drafted, paints the shortcomings of PSA screening with too broad a brush and fails to make any consideration of individual patient risk factors, including age, race, family history and comorbidities. High risk patients, including men with African-American ancestry, veterans, and those with a family history, should be considered distinct from the broader population, as reflected by the guidance of many medical societies and patient care groups. Furthermore, the stratification by age is an important component in all the societies’ guidance: • The American Urological Association recommends discussion about risks and benefits of PSA screening in men between the age of 55 and 69 years, and in men 40 to 54 years who are African-American or have family history of prostate cancer. • The American College of Physicians recommends discussion about risks and benefits of PSA screening in men between the age of 50 and 69 years. • The American Society of Clinical Oncology recommends discussion about risks and benefits of PSA screening in men with a life expectancy > 10 years. • The American Cancer Society recommends discussion about risks and benefits of PSA screening in men: over the age of 50 years who are at average risk of prostate cancer and are expected to live at least 10 more years, over the age of 45 years for African- Americans and men who have one first-degree relative diagnosed with prostate cancer at an age younger than 65 years, and over the age of 40 years for men with more than one first-degree relative diagnosed with prostate cancer at an age younger than 65 years. • The National Comprehensive Cancer Network recommends discussion about risks and benefits of PSA screening in men over the age of 45 years. That the USPSTF recommendation contradicts practice guidance issued by these expert groups reflects the flaws in the Task Force methodology more than any compelling science arguing against such basic exclusions for race and other risk factors. In October, the USPSTF initiated the process of updating its PSA recommendation. The public comment period on the draft research plan ended November 26, 2015. Making changes to the current recommendation about Medicare practices until this re-assessment has been completed would appear to be premature at best. ZERO strongly encourages CMS to delay further development of this measure until the USPSTF has completed its update process, including a thorough review of the latest literature and evidence. Finally, we believe the most important point in the discussion around appropriate use of the PSA test is that the potential harms associated with the use of the test itself are negligible, simply reflecting the potential harms associated a common blood draw. It is the potential harms associated with the improper treatment of prostate cancer that the Task Force seeks to mitigate. A more appropriate policy should discourage the overly aggressive use of invasive treatment for localized forms of low risk prostate cancer among men who are unlikely to have clinically significant prostate cancer that could lead to their deaths. Discouraging use of the PSA test in the early detection of prostate cancer will lead to an increase in the number of men diagnosed at an advanced stage of prostate cancer when the disease can no longer be cured with localized treatments. While the draft measure recognizes the value of PSA testing in men with a known elevation in the PSA level, or with a diagnosed disorder that affects PSA levels, it would effectively eliminate use of the PSA test in men with no clinical signs or symptoms of a prostatic disorder (prostate cancer specifically included). These exact groups of men, and particularly those who are otherwise healthy between the ages of 45 and 69, serve to benefit the most from a PSA test, which helps to diagnose men at risk for clinically significant prostate cancer before there are any signs and symptoms of the disease. This practice is clearly associated with (if not entirely responsible for) the decline in both the prostate cancer-specific mortality rate and in the risk of a metastatic prostate cancer diagnosis over the past 25 years. A national clinical quality measure should not be deeply divisive and controversial, as this PSA screening measure would be. Therefore, ZERO joins many other provider groups and patient advocacy organizations in urging CMS to abandon, or delay, this misguided effort. On behalf of the millions of men and their families fighting prostate cancer, we thank you for the opportunity to share these comments and look forward to working with CMS to ensure that men at risk for prostate cancer are diagnosed early and when diagnosed, receive appropriate treatment. Best Regards, Jamie Bearse President and CEO ZERO - The End of Prostate Cancer (Submitted by: ZERO - The End of Prostate Cancer)
Washington State Urology Society To: NQF CMS Quality Measures Committee From: Jeff Evans, MD Date: December 5, 2015 Re: Public Comment concerning NQF recommendation regarding PSA screening quality measure Members of NQF Quality Measures Committee: I am writing on behalf of the Washington State Urology Society (WSUS) membership regarding the NQF recommendation of using PSA screening as a quality measure. Most urology organizations and the American Cancer Society disagree with the “D” rating handed down by the US Preventative Services Task Force (USPSTF) May 21, 2012 regarding prostate cancer screening. The fallout of that decision has resulted in far less prostate cancers being diagnosed this year and we fear will lead to a higher number of prostate cancer deaths. NQF is taking the same view as the USPSTF and recommending PSA screening be linked to quality care. We feel this action would be very irresponsible and is politically and morally indefensible. CMS should not get in the middle of this statistical disagreement between the USPSTF (an organization that did not seek meaningful input from urologists, radiation oncologists or medical oncologists) and the experts that actually treat prostate cancer. Not getting a PSA should in no way be a quality measure unless not getting this test shows compromised quality. Prostate cancer is the 2nd leading cause of cancer death in men (kills more men than colon cancer). The advantages and disadvantages of PSA screening regarding survival are certainly debatable. Most of the controversy is regarding the interpretations of the Prostate, Lung, Colon and Ovarian Cancer Screening Trial (PLCO) and the European Randomized Study of Screening for Prostate Cancer (ERSPC). It is key to recognize the significant limitations of those studies when attempting to make policy decisions. The PLCO was a study of “some screening” v. “good screening” (i.e. pre-screening contamination). However, the PLCO still showed that in young men with no co-morbidities there was a statistically significant reduction in prostate cancer deaths. Updated data from ERSPC has demonstrated a 21% risk reduction in prostate cancer related death associated with screening (up to 29% after accounting for non-compliance). Regardless of how either study is interpreted, the U.S. 1990 age-adjusted death rate from prostate cancer was 39 per 100,000 and in 2009 was 18.5 per 100,000, likely from increased prostate cancer screening with the advent of widespread PSA testing. Additionally, the Goteborg Trial also showed a substantial 44% relative risk reduction in prostate cancer mortality in men 50-64 years after a median of 14 years. Importantly, the risk reduction occurred in a setting where many of the patients were not aggressively treated for prostate cancer, indicating that the harms of PSA-based screening can, in fact, be minimized by good clinical practice. The SEER Registry data demonstrates a 75% reduction in the proportion of men with prostate cancer who present with metastatic disease, as well as a 42% reduction in age-adjusted prostate cancer mortality during the PSA era. No other screening test available can boast such a dramatic reduction in the risk of developing metastatic disease. The relative survival at 10 years for a patient with localized prostate cancer was 72%, compared to 3% for a patient with distant (metastatic) disease. Models developed in our state at the University of Washington (CISNET) demonstrated that early detection through screening could account for approximately 45-70% of the decline in prostate cancer mortality under a “stage-shift” mechanism for screening benefit. The dialogue created by the USPSTF has done a disservice to our male patients in several ways. Blanket screening of men for screening is one thing, but patients with lower urinary/pelvic symptoms and patients at higher risk of death from prostate cancer are not even being screened adequately. The American Academy of Family Practice Choosing Wisely campaign has even recommended to never perform a rectal exam for screening purposes. What is the harm in a physical exam? Those at higher risk such as African Americans, patients with a significant family history and those with increased prostate cancer risk (e.g. Agent Orange exposure) are being denied shared decision making because of the “harms” of prostate cancer screening. What about the harms of not screening? Our organization is worried that Mathmetica’s recommendation to make PSA screening a quality measure will make appropriate evaluation in patients with symptoms, or those that are at increased risk, to be even less likely to receive a proper evaluation with PSA/DRE for fear of financial repercussions to the physician. Any urologist will attest to the fact that we are seeing an increase in advance prostate cancer in our clinics. The LHRH agonist/antagonist (initial treatment for metastatic disease) sales force will admit to a 3-4% increase in sales because of an increased presentation of metastatic prostate cancer over the last 4 years since the “PSA downgrade”. In the state of Washington our urologists have certainly noticed this. We all have stories of patients being denied PSA screening (despite requesting it) and then presenting back later with metastatic disease. We believe the “risks of screening” have been overstated as treatments become more precise and when less prostate cancers are being treated in an era where active surveillance has been embraced for low risk disease. The harms of treatment for metastatic prostate cancer therapy should be considered just as carefully given the greatly increased risk of metastatic disease in an unscreened population. As stage migration regresses back to the pre-PSA screening era, we will have more men on hormone deprivation, dealing with bone pain and pathologic fractures and urinary obstruction. Reverting back to a focus on shared decision making is very appropriate when considering all the recent improvements in screening tools, genomic testing and adoption of active surveillance (monitoring patients without active treatment) when medically appropriate. Active surveillance for low risk disease and improved screening tools such as 4K score, PCA3 and ERSPC risk calculator aid in the detection of intermediate and high grade disease prior to biopsy. Genomic testing on biopsy tissue such as Oncotype Dx and Prolaris are increasingly being used to aid in predicting those with very low and intermediate risk disease (eg. Oncotype Dx and Prolaris). Therefore, CMS should not interject themselves in this very polarizing debate regarding screening for prostate cancer. The WSUS suggests NQF not move forward with the recommendation to use PSA screening as a “quality measure”. Thank you for soliciting opinions and considering the WSUS position on this important topic. Feel free to reach out to us for any additional comment or resources we can offer you. We would appreciate your sincere consideration of important comments and eagerly look forward to your updated recommendations. Respectfully, Jeffrey L. Evans, MD President of Washington State Urology Society Cell: 206-852-3397 jeffreylewisevans@yahoo.com (Submitted by: Washington State Urology Society)
Malecare Cancer Support facilitate American's largest prostate cancer patient support network. We are also our country's leading men's cancer survivor support and advocacy national nonprofit organization, with a unique focus on African-American cancer survivorship. We ask that the use of the PSA test for screening of prostate cancer be left as a option for patients and doctors to utilize. (Submitted by: Malecare Cancer Support)
This measure would essentially take us back to the 1970's with no screening or preventative care for prostate cancer. Although there are certain cases of prostate cancer that may not require therapy, there are many serious and dangerous prostate cancers that would go undetected and lead to a significant number of patient deaths. It is very important to at least be able to establish a diagnosis on men in the range of 50-75 years so that options can be given to patients on treatment. A digital rectal examination is highly inadequate to be able to determine the need for a prostate biopsy and although PSA is not specific for cancer, it has been a very good test in reducing the prostate cancer death rates in this country. This measure of eliminating PSA is ridiculous and dangerous and is not at all in the best interests of patients! (Submitted by: Martin Health System)
I am a general internist and served as a member of both the American College of Physicians and the American Urological Association guideline panels on PSA screening. These guidelines differ from the USPSTF in that they recommend a “shared decision making” approach to PSA screening among men in the age range showing a prostate cancer mortality reduction in the ERSPC trial (approximately age 55-69). The one fewer death per 1000 men screened over 10 years (and about 1.3 fewer deaths over 13 years in the most recent ERSPC publication) is not dissimilar to the benefit seen with breast cancer screening. I believe the ERSPC yields a more valid estimate of the benefit of PSA screening compared to the PLCO trial in the United States, given less contamination of the control group with “usual care” PSA testing. Undoubtedly, PSA screening leads to substantial overdiagnosis and overtreatment, more so than with breast cancer screening. However, the balance of benefits and harms is close enough that I believe informed men of an appropriate age should have a strong say in whether or not to be screened. In our research, about a third of well-informed men (who have seen a patient decision aid and completed a knowledge test) still want a PSA test (Barry MJ, et al. Responses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices. Am J Prev Med. 2015 Oct;49(4):520-5). I would recommend that CMS develop a quality measure that discourages screening for men age 75 and older (too many of whom currently get PSA tests), and allows PSA screening only after documentation of a shared decision-making process including a decision aid for younger men. This approach would be similar to the recent CMS decision to cover low dose computerized tomography for lung cancer screening only after such a process has been completed. (Submitted by: Informed Medical Decisions Foundation)
December 7, 2015 BY ELECTRONIC SUBMISSION Elizabeth McGlynn, PhD, MPP Harold Pincus, MD Coordinating Committee Chairs Measure Applications Partnership National Quality Forum 1030 15th Street NW Suite 800 Washington DC 20005 Re: MUC15-1019 Non - Recommended PSA - Based Screening Dear Drs. McGlynn and Pincus, On behalf of LUGPA, we thank you for the opportunity to comment on the performance measure MUC15-1019 “unnecessary screening for prostate cancer using prostate - specific antigen (PSA).” LUGPA has significant clinical concerns regarding how the implementation of this policy as written will affect patient care; these concerns are based on several factors: 1. LUGPA (and other organizations representing physicians who care for or represent the interests of patients with prostate cancer) fundamentally disagrees with the scientific methodology on which the United States Preventative Services Task Force (USPSTF) based its Grade “D” recommendation regarding PSA-based prostate cancer screening; 2. Data regarding prostate cancer diagnosis suggest that the medical community’s response to the USPSTF recommendation may already have resulted in reduced detection of biologically significant cancer with resultant missed opportunity for curative intervention; and 3. The timing of the proposal is premature given the fact that the USPSTF itself is revisiting the issue of PSA-based prostate cancer screening. I. LUGPA In 2008, when physician leaders of large urology group practices began to recognize the need for a formal association to help meet the challenges of the future, LUGPA was initially established with the purpose of enhancing communication between large groups, allowing for benchmarking of operations, promoting quality clinical outcomes, developing new business opportunities, and improving advocacy and communication in the legislative and regulatory arenas. Since that time, LUGPA has expanded its mission to include smaller group practices that are equally committed to providing integrated, comprehensive services to patients suffering from genitourinary disease. LUGPA currently represents 121 urology group practices in the United States, with more than 2,000 physicians who collectively provide approximately 30% of the nation’s Urology services. Integrated urology practices are able to monitor health care outcomes and seek out medical “best practice” in an era increasingly focused on medical quality and the cost-effective delivery of medical services, as well as better meet the economic and administrative obstacles to successful practice. LUGPA’s mission is to provide urological surgeons committed to providing integrated, comprehensive care the means to access resources, technology, and management tools that will enable them to provide all services needed to care for patients with acute and chronic illnesses of the genitourinary system, including men with prostate cancer, in an efficient, cost-effective, and clinically superior manner, while using data collection to create parameters that demonstrate quality and value to patients, vendors, third party payors, and regulatory agencies and legislative bodies. Over the past several years, LUGPA has taken an active role in providing CMS and other governmental agencies, including the Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office (GAO), critical data and other information regarding diagnostic and therapeutic modalities used in providing prostate cancer care to Medicare beneficiaries. On numerous occasions, LUGPA representatives have met with senior leaders in all of these agencies, as well as with members of Congress, to discuss peer-reviewed and other empirical studies of the utilization of various modalities for diagnosing and treating prostate cancer in Medicare beneficiaries. In addition, LUGPA has provided comments to CMS on the Medicare Shared Savings Program/Accountable Care Organizations proposed rule and continues to take a leadership role with respect to proposed bundled payment systems for prostate biopsy services. We hope to continue the relationship we have established with CMS, MedPAC, GAO, and others by providing meaningful commentary to agency reports, inquiries, and proposals. Thus, we respectfully provide the following comments on the proposed measure regarding non-recommended PSA-based prostate cancer screening. II. The Scientific Underpinning of the USPSTF Recommendation is Flawed We do not believe that USPSTF reached a correct conclusion regarding the clinical value of PSA screening. In fact, we believe that the task force decision is based on incomplete data, an inappropriate superimposition of the risks of therapy onto the risks of screening and a misunderstanding for clinical changes that are occurring presently in the real world management of PSA screening in conjunction with the shared decision making being offered to patients with newly diagnosed prostate cancer in the United States today. At the time of the recommendation we expressed concern that great harm will ensue for patients with intermediate and high risk localized prostate cancer as well as those already with advanced, asymptomatic metastatic disease, unintended victims of collateral damage as a consequence of the USPSTF recommendation to avoid the overtreatment of prostate cancer patients with low risk disease. The authors of the supporting review article in the Annals of Internal Medicine (Chou et al.) and members of the USPSTF shared a number of distinct characteristics that are troublesome: a void of urology, urologic oncology, radiation oncology or medical oncology inclusion; some authors are not physicians and it is unclear for those who are physicians if they are in active practice. Hence, the review authors and the USPSTF together may lack certain clinical insights that would assist them to understand: 1) the significant clinical concerns and consequences of their recent f PSA screening recommendations in this country and worldwide, 2) the educated and appropriate use for PSA screening, 3) PSA utilization in conjunction with the rapidly advancing field of compendium and complimentary biomarkers and how the screening efficiency has rapidly changed in the last 2 years and 4) ultimately, best practices for the future. It is critical to the discussion of screening to differentiate risks of screening from risks of treatment. Unfortunately, the section of the draft document on Harms of Screening and Treatment virtually ignores the physical risks of screening, focusing entirely on risks of biopsy and treatment. Actual physical risks of the screening process itself are minimal: PLCO reports a combined incidence of 26.3 events per 10,000 men screened, or 0.26%. It is not common clinical practice to automatically biopsy every patient detected on PSA screening; there are many factors that influence this decision including free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and other comorbidities. In making its recommendation, the USPSTF acknowledged that the existing studies on prostate cancer screening had very significant methodological flaws, as agreed upon by the authors of the manuscript as well; in fact, two studies were characterized as “fair.” However, it was unclear as to the method by which these two studies (the Prostate, Lung, Colorectal and, Ovarian Cancer Screening Trial (PLCO) and the European Randomised Screening for Prostate Cancer (ERSPC) trial) were weighted. It was clear that the panel gives enormous weight to the PLCO study and virtually disregards the findings of the ERSPC; however, the flaws in the PLCO study appear much deeper than those in the ERSPC. Please consider the following: 1. The panel states that overall mortality is the goal studied by all trials reviewed. This is simply untrue. The ERSPC and Göteburg trials were specifically statistically powered to evaluate prostate cancer specific mortality (PCSM), not all cause mortality. Overall mortality provided a parameter for assessing randomization rather than serving as an end point in itself. Dismissing the importance of a statistically significant 20% reduction in the overall PCSM for ERSPC and 44% reduction of PCSM in the Göteburg component as “small to none” misses the clear clinical benefit to these patients and their families. 2. The PLCO study recruited 40% of men with a history of prior screening into their control arm. Furthermore, as the control arm was defined as “usual care,” and not “no screening,” patients were continued to be allowed to receive PSA testing during the study interval, resulting in screening being performed in >50% of the “control” arm, thus diluting the differential impact of PSA screening. Other than a statement that the authors attempted to correct for this, the USPSTF does not discuss their appreciation of this obvious error. 3. Although the major randomization error in (2) above is mentioned in passing, the following significant flaws in the PLCO do not appear to have been considered by the panel: a. Only approximately 40% of patients in the screening population who screened positive actually underwent prostate biopsy. b. The overall follow-up with 98% mortality data in the PLCO trial was only 7 years. 4. These errors in the PLCO, not mentioned in the USPSTF recommendations, reveal that the PLCO report is inconsistent with the characteristics of a screening trial. Although the percentage of cancers in screened patients (7.4%) was higher than seen in “usual care” men (6.1%), this difference is far less than would be expected in a screened vs. unscreened population. Consider that in the ERSPC, the reported figures were 8.2% vs. 4.8%, respectively. Additionally, in PLCO, the presence of stage III/IV disease was nearly the same (122 in screened vs. 133 in “usual care”) compared to what is consistent with screened vs. unscreened studies like ERSPC where unscreened men were much more likely to have higher stage disease and, indeed, they did, with 41% more positive bone scans compared to screened men at diagnosis. There exist today multiple unmet needs in caring for men with prostate cancer. Curing men with localized high risk disease is tantamount to reducing the approximate 28,000 annual cause specific mortality within the US; furthermore, while ~5% of the newly diagnosed prostate cancer patients within the US present with metastatic disease, the urologic oncology community goals are not to increase that percentage population but rather to identify them as early as possible in order to initiate our many recently approved therapies and thus avoid the sequelae of this disease. 5. There is no mention of 2 sub-group analysis in the PLCO trial showing survival benefits: a. About 10% of both controls and usual care men had undergone 2 or more PSA tests before randomization; their PCSM was 25% lower than men not tested and b. A later study of a healthier sub-group of PLCO men by Crawford showed a 44% survival benefit. This discounting of the then-available data from the ERSPC study was subsequently shown as erroneous. In its 2012 update, the ERSPC data demonstrated a 21% survival advantage to PSA screening for all patients, and furthermore, for those with the longest follow-up (over 10 years) this increased to 38%. As such, the screening efficiency of PSA testing in this study is similar to that reported for breast or colo-rectal cancer; CMS is not proposing elimination of screening for these diseases. II. CMS Must Consider the Impact of the USPSTF Recommendation on Trends in Prostate Cancer Diagnosis Before any further policy change is suggested in PSA testing in the United States, particularly one that proposes to encourage physicians and EPs with remunerative gain who do not order PSA tests in any men, it is appropriate to regard the changes that have already occurred in the prostate cancer field since the controversy surrounding the USPSTF Grade D recommendation against PSA testing began in 2011, culminating in its publication in 2012. In a relatively short period of time, we have already seen a number of studies reflecting a significant and concerning change not only in the number of prostate cancers diagnosed, but also the stage and grade of newly diagnosed patients. Even if a causal link has yet to be definitively established, it is clear that a temporally related effect of the USPSTF Grade D recommendation has been associated with a decrease in the incidence of prostate cancer screening in the US. Originally these studies emanated from individual hospitals or health care systems; they clearly indicated significant reductions in PSA testing, referrals for elevated PSA, performance of prostate biopsies and lower detection rates of prostate cancer. , , More recent studies have reflected similar changes nationally. One study based on the National Health Interview Survey (NHIS) showed significant declines in PSA based screening in men over age 50: the decline was from 33.2% to 24.8% in men ages 50- 59 and from 51.2% to 43.6% in men ages 60 -74. A review of the National Cancer Database (NCBD) and revealed a national decrease of 28% in incident diagnoses of prostate cancer in the single year after the USPSTF draft recommendation. Similarly, a review of SEER data was recently shown to show a precipitous decrease in prostate cancer detection in men over 50, from 213,562 men in 2011 to 180,043 men in 2012: a drop of 33,519 cancers detected in a single year! A recent review, again examining the NHIS, studying responses from >20,000 men before and after the USPSTF decision, found that the largest declines in men reporting PSA screening occurred between 2010 and 2013 and the declines were greatest in men between the ages of 50-54 (from 23% to 18%) and men ages 60-64 (from 45% to 35%). These declines were greater than observed in the elderly population - exactly the population with the most potential for benefit. In addition to the incidence of PSA screening and actual detection of prostate cancer falling after the USPSTF publication, there is also mounting evidence that the cancers being found are of higher risk. An analysis of National Oncology Data Alliance records of men with newly diagnosed prostate cancers in the US, reported that the number of men whose PSA levels were > 10 at diagnosis gradually dropped between 2005-2010; however, the number of men whose PSA levels were > 10 at the time of diagnosis rose 3% annually between 2011-2013, suggesting that cancers were being detected later. Further, in another single institutional study, there was reported a 31% reduction in prostate biopsies two and a half years after the USPSTF recommendation. These authors also reported a statistically higher PSA level at diagnosis, as well as significantly higher clinical stages detected, along with higher D’Amico risk scores at the time of diagnosis. These findings caused the authors to conclude that the reduction of prostate biopsies occurred concomitantly with a decrease in the detection of potentially curable prostate cancer and to suggest that repeat efforts at screening might be needed to prevent the reversal of decades of improvement in the prostate cancer mortality rate. Most recently, a review of over 10,000 patients compared positive biopsy rates, Gleason score and number of positive cores prior and subsequent to the USPSTF recommendation against PSA screening. Compared to the two years prior to the USPSTF final recommendation: 1) positive biopsy rates increased from 39 to 46 percent; 2) in newly diagnosed cancers, the percent of Gleason 8-10 cancers rose from 14.8 to over 25%; and 3) there was a 4.5% increase in positive cores/patient. The authors suggested that these changes could portend a loss of advantages previously realized in prostate cancer mortality since PSA screening became a common clinical practice III. The USPSTF is in the Process of Reviewing the Issue of Prostate Screening Despite the objections of those most intimately involved in prostate cancer diagnosis and treatment, the USPSTF opted to finalize its grade “D” recommendation on prostate cancer screening. This decision (among others), and the relative lack of transparency associated with the USPSTF process, has prompted legislators to act in a bipartisan, bicameral manner to propose changes in the manner in which the USPSTF conducts its reviews. The USPSTF Transparency and Accountability Act of 2015, introduced by Reps. Marsha Blackburn (R-TN-7) and Bobby Rush (D-IL-1) is the vehicle to reform the USPSTF process. This legislation aims to reform the process by which the U.S. Preventive Services Task Force (USPSTF) reviews and develops recommendations for clinical preventive services; a process that is currently exempt from transparency provisions such as the Federal Advisory Committee Act (FACA) and the Administrative Procedures Act (APA). The bill includes a critically important mandate to ensure that a “balanced representation of primary and specialty care providers” and other key stakeholders in the healthcare community are involved in development and review of USPSTF recommendations. Other changes include publishing a draft research plan to guide the systematic evidence review process; considering findings and research by federal agencies and departments; and making the evidence review available for public comment. Whether in response to potential legislative reforms or due to a recognition that its original one-size-fits-all recommendation disadvantaged patients at higher risk for developing prostate cancer, the USPSTF is planning to update their 2012 decision and has already issued a “Draft Research Plan for Prostate Cancer: Screening” with opportunities for comment by interested parties by November 26, 2015.These new guidelines might be available as soon as 2017. IV. Summary Given the aforementioned detrimental trends that have already occurred since the USPSTF decision, LUGPA is deeply concerned that we now will compound these changes by promising a financial benefit to doctors and other EPs who decide against PSA testing. LUGPA believes is it time to review and revise the potential harm caused by recommending against prostate cancer screening in its entirety; of note, given the natural history of prostate cancer diagnosis to death, whether initially localized or metastatic upon presentation, it is imperative that we utilize the most current literature available to make policy decisions to avoid escalating prostate cancer as the 2nd leading cause of male US cancer mortality. LUGPA is committed to contemporaneous review of the current literature and evidenced based medicine evidence regarding screening, diagnosis, and management of this disease. As such, we are concerned that the literature cited by CMS simply does not reflect the current state of knowledge regarding either prostate cancer screening processes or the potential impact of the USPSTF recommendations on stage and grade migration. A brief review of the framing document produced by this entity reveals a lack of familiarity and depth in preparing for this task, with not a single reference cited beyond 2013. On behalf of LUGPA, we would like to thank you for providing us with this opportunity to comment on the performance measure. Please feel free to contact Dr. Kapoor at (516) 342-8170 or dkapoor@impplc.com if you have any questions or if LUGPA can provide additional information to assist CMS as it considers this issue. Respectfully submitted, Deepak A. Kapoor, M.D. Carl A Olsson, MD Chairman, Health Policy LUGPA Clinical Associate Professor of Urology The Icahn School of Medicine at Mount Sinai Chief Medical Officer Integrated Medical Professionals, PLLC Director of Quality Initiatives and Strategy, Department of Urology The Icahn School of Medicine at Mount Sinai 1. Centers for Medicare and Medicaid Services, Medicare Provider Utilization and Payment Data: Physician and Other Supplier, available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html. 2. Andriole GL, Crawford ED, Grubb RL 3rd, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310-9 3. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-8. 4. Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725-32 5. Schröder FH. Stratifying Risk — The U.S. Preventive Services Task Force and Prostate-Cancer Screening. N Engl J Med. 2011; doi 10.1056/NEJMp1112140, published October 26, 2011. 6.Crawford, ED, Grubb III, R, Black, A, et al. Co-morbidity and Mortality Results From a Randomized Prostate Cancer Screening Trial. J Clin Onc 2011; 29(4): 355-361 7. Schröder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366:981-990). 8. Greene R, Tausch T, Deo Perez D et al. An Examination of PSA Utilization and Referral Patterns in a Large Integrated Health Care System Following the US Preventative Services Task Force Recommendations. J Urol 2013; 189(4S): e513 9. Aslani A, Minnillo BJ, Johnson B, et al. The Impact of Recent Screening Recommendations on Prostate Cancer Screening in a Large Health Care System. J Urol 2013; 191(6):1737 10. Bhindi B, Mamdani M, Kulkarni GS, et al.Impact of the U.S. Preventive Services Task Force Recommendations against Prostate Specific Antigen Screening on Prostate Biopsy and Cancer Detection Rates. J Urol 2015; 193: 1519 11. Drazer M, Huo D, Eggene, S. National prostate cancer screening rates after the 2012 US Preventive Services Task Force recommendations discouraging prostate-cancer-specific antigen-based screening. J Clin Oncol. 2015; 33: 2416 12 Barocas DA, Mallin K, Graves AJ et al. The effect of the U. S. Preventive Services Task Force grade D recommendation against screening for prostate cancer on incident prostate cancer diagnoses in the United States. J Urol. 2015; 194: 1587 13. Jemal A, Fedewa SA, Ma J, et al. Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations. JAMA. 2015 Nov 7;314(19):2054-2061. 14. Sammon JD, Abdollah F, Choueiri TK, et al. Prostate-Specific Antigen Screening After 2012 US Preventive Services Task Force Recommendations. JAMA. 2015 Nov 17;314(19):2077-2079. 15. Hall MD, Schultheiss TE, Farino G, et al.: Increase in higher risk prostate cancer cases following new screening recommendation by the US Preventive Services Task Force (USPSTF). J Clin Oncol 33, 2015 (suppl 7; abstr 143) 16. Banerji JS, Wolff EM, Massman JD III et al: Prostate needle biopsy outcomes in the era of the U.S. Preventive Services Task Force recommendations against PSA based screening. J Urol 2015. 17. Olsson CA, Anderson A, Kapoor DA. Persistent Adverse Trends in Histology of Newly Diagnosed Prostate Cancer Subsequent to USPSTF PSA Screening Recommendation. Society of Urologic Oncology Annual Meeting, Washington DC – 12/2015. 18. Draft Research Plan for Prostate Cancer: Screening. Accessed at: http://www.uspreventiveservicestaskforce.org/Page/Document/draft-research-plan/prostate-cancer-screening (Submitted by: LUGPA)
I am very concerned about using PSA testing as a measure of poor quality. My 57 year old accountant has incurable prostate cancer because his primary care provider was an early adopter of this foolishness. As a urologist in a muiltispecialty physician group, this is just the most personal example of patients that my partners and I see on a regular basis. When I finished residency in 1992, >40,000 men DIED of prostate cancer per year in the US. Today is it <20,000. The difference? PSA testing to catch the disease in it's early stages. Shared decision making between the patient and his physician can only be effective with adeqate data. PSA (and digital rectal exam) are at this time the best we have to deal with this common cancer in men. Since prostate cancer is more prevalent in African American men, this measure could be interpreted as racist as well (Submitted by: Olympic Medical Physicians)
December 1, 2015 Comments for proposed Clinical Quality Measure: MUC ID – “MUC15-1019” Measure Title - “Non-Recommended PSA-Based Screening” Description – “Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening.” Measure Type – “Process” Measure Steward – “Centers for Medicare & Medicaid Services” CMS Program – “MIPS” Submitted by: Men’s Health Network Men's Health Network (MHN) is a national non-profit organization whose mission is to reach men, boys, and their families where they live, work, play, and pray with health awareness and disease prevention messages and tools, screening programs, educational materials, advocacy opportunities, and patient navigation. MHN appreciates the opportunity to provide comments on the draft clinical quality measure developed by the National Quality Forum regarding “Non-Recommended PSA-Based Screening.” We have serious concerns about this proposed measure and the impact it would have on men who would benefit from early detection of prostate cancer. We thank you for considering the comments outlined below. We understand that the development of this clinical quality measure is based in large part on the “D” recommendation given to PSA screening by the United States Preventive Services Task Force (USPSTF) in 2012. This recommendation has been very controversial and is not supported by the majority of professional associations and prostate cancer advocacy organizations. Also, notably, prostate cancer screening is currently under review again by the USPSTF, making CMS consideration of this clinical quality measure seemingly premature. http://www.uspreventiveservicestaskforce.org/Page/Document/draft-research-plan/prostate-cancer-screening1 The use of the PSA as an early indicator that the individual’s prostate may have or be developing abnormal conditions is too often mischaracterized as a cancer test. It is not, but is useful in detecting non-symptomatic prostate cancer, as well as other abnormalities in the prostate. The PSA is also useful in tracking the progress of prostate cancer, or lack of progress, once detected. The medical community understands these limitations, and does not use the PSA as a stand-alone cancer test, instead using it as an indication of prostate health, and in combination with other tests to determine if prostate cancer might be present. The risk of “harms” associated with the test are minimal, and no different from any other blood draw, procedures that are used to determine cholesterol and glucose levels daily in every medical setting across the country. This is a simple test that has helped diagnose thousands of men who had potentially life-threatening prostate cancer, but had no idea they might be at risk. It has also helped discover many more prostate cancers that would never be life threatening, and that might never be treated, but, instead, may be carefully monitored to ensure that the cancer does not progress. The decision to treat prostate cancer, once identified – or to engage in either active monitoring (active surveillance) or passive monitoring (watchful waiting) – is a decision to be made by a man in consultation with his physician and his family. This process is entirely separate from the screening decision. Leading organizations including the American Urological Association, the American Cancer Society, and the National Comprehensive Cancer Network have each issued their own, more nuanced, guidance recommending discussions between patients and providers on PSA and other screening tools in the early detection of prostate cancer. New technologies are now being used in conjunction with PSA testing to help determine the likelihood of aggressive prostate cancer and guide treatment decisions, and while PSA may eventually be replaced by more precise screening tools, it is currently an essential option for patients and providers in the early diagnosis of clinically significant prostate cancer. The effect of this quality measure would be to discourage the important conversation between a health care provider and the patient to determine if the patient might benefit from prostate cancer screening, a screening which may include a PSA. This would discourage discussions with men who know they might be at high risk for prostate cancer because of race, ethnicity, family history, age, or exposure to certain carcinogens such as Agent Orange and the dust and debris from the World Trade Center disaster. It would also discourage similar talks with men who do not know their family medical history. Failure to have those discussions will mean many of these men are diagnosed with later stage prostate cancer, condemning them to painful, perhaps life-threatening, experiences in their fight for survival. We agree with one physician who states that the quality measure is misdirected and that the treatment (and decision to treat or not) should be the quality metric, rewarding appropriate care, and not rewarding inappropriate care: “Instead of using PSA screening (or lack thereof) as a quality metric, how about using treatment as a quality metric? Why not use the EHR to see who is treating low-risk prostate cancer inappropriately? Or use the EHR to see who is ordering inappropriate CT scans or bone scans? Let’s monetize appropriate care, not monetize the wholesale disruption of PSA screening.” Benjamin Davies MD, Urologic Oncologist and Associate Professor of Urology at the University of Pittsburgh. Chief of Urology at UPMC Shadyside Hospital and Director of the Urologic Oncology Fellowship at the University of Pittsburgh. www.forbes.com/sites/benjamindavies/2015/11/15/the-governments-war-against-mens-health-its-about-to-get-worse Thank you for your thoughtful consideration of these comments. (Submitted by: Men's Health Network)
The AMA recognizes that this measure has been created in response to the USPSTF recommendations against PSA screening regardless of age. This recommendation conflicts with the current recommendations released by the American Urological Association in 2013, which emphasizes that an individual’s values and preferences must be taken into account and for this reason the recommendation focuses on shared decision-making between the physician and patient. We are concerned that this measure as currently specified could negatively impact the physician-patient relationship and should not be recommended until the concept of shared decision-making and the discrepancy between the guidelines are addressed. In addition, USPSTF is in the process of reviewing the literature again with a possible update to the recommendations. Therefore, given the timeline for updates, we believe it is premature to move forward with a measure based on the USPTSF recommendations. (Submitted by: American Medical Association)
The American Association of Clinical Urologists (AACU), a professional association representing thousands of urologists from across the country, appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) quality measure under development entitled, “Non-Recommended PSA-Based Screening.” The AACU opposes the adoption of this proposed quality measure. The AACU opposes any attempt to use the ordering of a prostate-specific antigen (PSA) test as a negative quality measure. Multiple experts in the diagnosis and treatment of prostate cancer who have researched PSA-based testing have found PSA-based testing to be an effective diagnostic tool. The AACU and its urologist members, in addition to other leading societies, have emphasized the importance of an individualized decision on PSA-based testing between the patient and the physician. Physicians should not be penalized for ordering a test that, while not perfect, has long been recognized as an important tool in the diagnosis of prostate cancer. The AACU has strong concerns over the impact the adoption of this proposed quality measure would have on the early diagnosis and evaluation of patients with prostate cancer. Accordingly, the AACU opposes any use or adoption of the proposed quality measure entitled, “Non-Recommended PSA-Based Screening.” The AACU appreciates the opportunity to comment and is available for questions. Jeffrey M. Frankel, MD Health Policy Chair, American Association of Clinical Urologists (Submitted by: American Association of Clinical Urologists)
The American Urological Association (AUA) is highly concerned about measure MUC 15-1019 (non-recommended PSA-based screening) and its potential to negatively impact patient care. Despite differences of opinion about the role of PSA-screening for prostate cancer, discussion about the risks and benefits of PSA screening in targeted populations is advocated by many leading societies, including the American College of Physicians, the American Society of Clinical Oncology, the American Cancer Society, the National Comprehensive Cancer Network and the AUA. In contrast, the measure as proposed will incentivize providers to disregard patient and clinician discussion about PSA screening, thereby obviating the patient’s right to information about risks and benefits, and thus, completely preventing any attempt at shared decision making. Additionally, the measure addresses the shortcomings of routine PSA screening without consideration of age/comorbidities, individualized risk for prostate cancer and patient preferences. The proposed measure does not provide exclusions for men at high risk, including African Americans and those with a family history of prostate cancer. This high risk group is a critical patient population which many medical societies, including the AUA, specifically state should be considered distinct from the broader population. Furthermore, this measure is a process measure with no link to outcomes. It is based on the current recommendation of the United States Preventive Services Task Force (USPSTF) and a HEDIS measure that only focuses on PSA-based screening in men 70 years and older. The USPSTF is now in the process of updating this specific recommendation (currently in the phase of public comment about research methodology). Therefore, the AUA urges that this measure not be considered for inclusion in the Merit-Based Incentive Payment System (MIPS) or Physician Compare until the task force has reviewed the literature, analyzed the evidence, and completed its update process. The stratification by age is an important component of the AUA’s guideline recommendations. After the 2013 release of its guideline on early detection of prostate cancer, the AUA has been engaged in ongoing efforts to optimize the use of PSA testing, relying heavily on the guideline recommendations which are stratified by age and further educating members on the importance of shared decision making through publication of a white paper (2015) and implementation of a quality improvement summit (to be convened in 2016) to assist members in the use of decision aids, communicating with patients/families, and clarifying values of importance to the patient. Ultimately, this measure, as currently drafted, would be detrimental to patient care, and the AUA strongly recommends that the MAP reject this measure based on the issues outlined above. Penalizing providers for PSA testing will significantly restrict the opportunity for shared decision making and patient involvement in their own care. Thank you for the opportunity to provide input. (Submitted by: American Urological Association)
As a practicing oncologist, I am seeing more and more high risk and metastatic prostate cancer since the UPSTF recommendation against PSA screening. Further reducing PSA screening will lead to more advanced disease diagnosed in men, more aggressive therapy (including toxic chemotherapy), more morbidity from treatment of the more adcanced disease, more harm from metastatic and locally advanced disease and more deaths from prostate cancer. PSA screening is crucial to saving patients from these outcomes and further limiting this is an attack on the health and well being of men along with their ability to manage their own health in an informed manner. (Submitted by: Rainier Cancer Center)
The U.S. Centers for Medicare and Medicaid Services ("CMS") is proposing an outrageous measure that will set back men’s health and cause great harm, including unnecessary death. The proposed measure, which discourages screening for prostate cancer, should get the attention and action of all men, particularly Black men. Prostate cancer diagnoses, aggressive cases, and deaths are extraordinarily high among Black men, twice that of their White counterparts. The prostate cancer incidence rate for White men is 130 cases per 100,000 vs. 215 cases per 100,000 for Black men and twice the mortality rate of 19 vs. 46 per 100,000. Nonetheless, the proposed “Non-Recommended PSA-Based Screening” measure discourages PSA (prostate-specific antigen) screenings in all men, regardless of age or risk factors. The proposed measure is based upon insufficient data and flawed, unreliable methodology of the U.S. Preventive Services Task Force. The Task Force, stunningly, dismisses a whole population of men who are disproportionately burdened with prostate cancer. The Task Force maintains, the harm from screening outweighs the benefits of screening. The Task Force reports that: “Although prostate cancer is very common, in many cases, the cancer does not grow or cause symptoms. If it does grow, it often grows so slowly that it isn’t likely to cause health problems during a man’s lifetime. The PSA screening test often suggests that prostate cancer may be present when there is no cancer, a false positive. False-positive results cause worry and anxiety and can lead to follow-up tests that aren’t needed. These tests can cause harms such as fever, infection, bleeding, urinary problems, and pain. A small number of men will need to go to the hospital because of these complications.” Surely, the men and families of the 250,000+ men who are diagnosed each year and the 27,000+ men who died last year from prostate cancer, beg to differ. What of the high risk population? The proposed measure would also potentially be used in all of Medicare's reporting programs and would financially penalize providers who order a prostate cancer screening test (PSA) for a patient whether he is high risk or not. As expressed by Dr. James Bennett, the highly-regarded Atlanta, Georgia based urologist and surgeon, this potential change in Medicare coverage is akin to the Tuskegee Experiment and must be vehemently opposed. Says Dr. Bennett: “As a practice that primarily deals with African American patients, we know based upon our years of detecting prostate cancer early for thousands of patents through PSA screenings that this measure will set back early detection of prostate cancer of this high risk group 30 to 40 years. It is disturbing that this ruling restricts PSA screenings, but has not given us an alternative measure to address the high incidence and mortality rate of African American men or men who have a significant family history of prostate cancer.” It is apparent that the CMS and the U.S. Preventive Services Task Force are not familiar with the pre-PSA era when prostate cancer was discovered in African American men in advanced and incurable stages. The proposed measure doesn’t take any of these medical facts and data into account. Could it be because the U.S. Preventive Services Task Force doesn’t even include an oncologist or urologist on its 16-member task force? The proposed measure also contradicts the practice guidance of the American Urological Association, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American College of Physicians-American Society of Internal Medicine and the American Cancer Society. This is clearly and simply a matter of life and death for a whole population of men. What CMS is proposing is not only unconscionable and summarily dismissive, but immoral and deadly. The PSA has worked for decades, and has enabled physicians to save the lives of many men by detecting prostate cancer early and before the cancer metastasizes. Every man who needs a PSA screening must be able to get it. The Prostate Cancer Advisory Council based in Atlanta, Georgia, is an advocacy group composed of Black and White men dedicated to helping bring about more awareness to all issues around prostate cancer and educate all men about the importance of regular medical check-ups and PSA screenings. We call upon the CMS to 1) reject the flawed recommendation of the Task Force and 2) to reconstitute the Task Force so that it includes oncologists and urologists who are devoted to the care, prevention, and treatment of prostate cancer. Prostate Cancer Advisory Council - Atlanta Our members include: Dr. James Bennett, Ambassador Andrew Young, Dr. Walter Young, Erroll Davis, John Guillory, Attorney Hank Fellows, Harold Lewis, among others. (Submitted by: Midtown Urology)
At least one NRHI member has concerns with this measure. There is concern that this measure has not tested well in the field, and that it could potentially discourage clinicians from conducting necessary screenings. (Submitted by: Network for Regional Healthcare Improvement)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
As a prostate cancer survivor, spokesperson for the Know Your Stats® About Prostate Cancer campaign and Pro Football Hall of Fame member, I am writing to express my strongest concern about measure MUC 15-1019 (non-recommended PSA-based screening) and its potential to negatively impact patient care. The Know Your Stats® campaign, a partnership between the Urology Care Foundation and the National Football League (NFL), is a rallying force to connect, educate and inspire men across the country to know their prostate cancer risk and to talk to their doctor about whether prostate cancer testing is right for them. For nearly 10 years, our mission has been to increase the cure rate of prostate cancer by educating men, particularly those at high risk for the disease, about the importance of early detection to prostate cancer outcomes and the latest in prostate cancer screening. Ultimately, this measure, as currently drafted, would be detrimental to patient care. Prostate cancer is the most common cancer among men, and the second-leading cause of cancer death in men. Key prostate cancer risks include race and family history. African American men are twice as likely to develop the disease as Caucasian men and one in three men with a family history of prostate cancer will be diagnosed with the disease. Because of these and other factors, the decision to have a PSA test should be between the patient and their physician and include a discussion about the patient’s risk factors and the benefits and harms associated with testing as well as subsequent tests (e.g., biopsy). Shared decision-making is critical – and the decision to get tested isn’t one to be made outside the context of a detailed conversation with a physician. I can tell you that if the decision to have a PSA test was not available to me when I met with my doctor several years ago, I may not be writing this letter to you today nor working on a daily basis to educate men about their prostate health, and potentially saving lives. My journey with prostate cancer started in Canton, Ohio at the Pro-football Hall of Fame. The American Urological Association’s official Foundation, the Urology Care Foundation, had teamed up with the NFL to offer prostate cancer screenings to retired players. After having a discussion with my doctor about my prostate cancer risks, I participated in their very first screening. Based on the results from my screening and a rise in my PSA, my doctor and I decided on a biopsy. Twelve core samples were taken as part of the biopsy – six on each side of the urethra. To my surprise, cancer was found in nine of the twelve places. My life was saved by a simple prostate exam. I am living proof of the power knowing your risk and talking to your doctor! As drafted, the measure on PSA screening disregards shared decision making, consideration of age/comorbidities, individualized risk for prostate cancer and patient preferences. I am afraid this would prevent much-needed discussions between physicians and patients about prostate cancer and could result in tests not being ordered even if a man wants to be screened. The proposed measure does not provide exclusions for men at high risk, including African Americans and those with a family history of prostate cancer. This high risk group is a critical patient population which many medical societies, including the American Urological Association, specifically state should be considered distinct from the broader population. Despite substantial disagreement about the role of PSA-screening for prostate cancer, discussion about the risks and benefits of PSA screening in targeted populations is advocated by many leading societies, including the American Urological Association, American College of Physicians, the American Society of Clinical Oncology, the American Cancer Society, and the National Comprehensive Cancer Network. In contrast, the measure as proposed will incentivize providers to disregard patient and clinician discussion about PSA screening, thereby obviating the patient’s right to information about risks and benefits, and thus, completely preventing any attempt at shared decision making. I also note that this measure is based on the current recommendation of the United States Preventive Services Task Force (USPSTF) that only focuses on PSA-based screening in men 70 years and older. The USPSTF is now in the process of updating this specific recommendation (currently in the phase of public comment about research methodology). Therefore, I urge that this measure be withdrawn until the task force has reviewed the literature, analyzed the evidence, and completed its update process. The stakes are just too high for us not to be talking about prostate cancer. Don’t sit on the sidelines, I urge the National Quality Forum to withdraw this measure rather than finalize a measure that may restrict the opportunity for shared decision making and patient input. Thank you for the opportunity to provide feedback. (Submitted by: Know Your Stats® About Prostate Cancer )

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

While the AMA supports the general concept that this measure attempts to address-- opioid overuse, we are concerned that the measure as currently specified is not actionable by the physician. We do not consider reporting on the number of patients for whom the number and frequency of opioid prescriptions could be potentially inappropriate to be a quality measure that accurately reflects a physician's care for patients. (Submitted by: American Medical Association)
Due to the national opioid epidemic, we respectfully request clarification on the denominator for length of supply and number of consecutive days. (Submitted by: American Society of Plastic Surgeons)
While TFAH supports addressing the opioid overuse epidemic in America, including through the Medicare program, we have several questions regarding this measure. The nonmedical use of prescription drugs, including opioids, and the corresponding injuries and deaths, constitute a growing public health crisis. In a TFAH report on how states are addressing the problem, we recommended, among a range of other steps, that “all providers should receive education and continued training about appropriate prescribing of commonly abused medications.” We do believe, however, that a physician measure related to this topic must be implemented in a way that appropriately balances limits on overuse with ensuring appropriate access to pain management. The measure under consideration is defined as “Patients of the Medicare prescribing provider whose daily morphine equivalent dose (MED) is greater than 90 mg for at least 90 consecutive days.” It would be helpful if CMS would provide further information about how this MED was established. We also note that in a recent update on the Medicare Part D Overutilization Monitoring System, CMS defines high-risk beneficiaries or “potential opioid overutilizers” as those with cumulative MED of at least 120 mg for at least 90 consecutive days, (as opposed to 90 MED), and also adds the criteria that the prescriptions are associated with more than 3 prescribers and more than 3 pharmacies. Those additional criteria would presumably help focus the program on beneficiaries whose prescriptions may not be well coordinated among providers; they are not, however, reflected in the “Potential Opioid Overuse” measure under consideration. In addition, while the “Potential Opioid Overuse” measure includes some exceptions, they are limited, and there is no indication of how “potential” overuse would be assessed to determine if it is in fact medically inappropriate. We are concerned that a measure based on the mere “potential” for overuse could have a chilling effect on legitimate prescribing activities. We would like to see further clarification, as the process moves along, of how the 90 MED for 90 days measure would be implemented in a way that is based on scientific consensus and meaningfully reflects prescriber attention to potential opioid overuse while maintaining appropriate access for pain patients with a legitimate need for the medications. Relatedly, we note that the current Physician Quality Reporting System (PQRS), which will be rolled into the new MIPS program, includes a measure on “Pain Assessment and Followup.” We strongly urge CMS to maintain this measure in MIPS, and to continue to develop measures that reflect a meaningful balance between addressing opioid overuse and assessing legitimate patient need for broad, comprehensive pain treatment approaches. (Submitted by: Trust for America's Health)
Several NRHI members expressed support for this measure. (Submitted by: Network for Regional Healthcare Improvement)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

We support the inclusion of this measure that is part of the American Academy of Dermatology (AAD) strategy to provide a comprehensive quality approach for patients with skin cancer. Including this measure will further expand performance measurement through the entire skin cancer care process. Each has been developed to address either a rate limiting step to quality care or a significant waste/overuse issue This is a measure of preventive care for people who have received organ transplants. The life-saving medicines that prevent organ rejection suppress the immune system, greatly increasing the risk of skin cancer. The chance of developing a NMSC ranges from 10 to 60 percent at the 5 and 20 year marks post-transplant, respectively. In organ-transplant recipients, skin cancer tends to be more aggressive: it grows faster and spreads more quickly. Counseling, screening and early treatment is critical to limiting the harm of skin cancer. This measure also fills a critical program need for measures of skin care as there are only 6 dermatology-specific measures in PQRS and none in the NQS category of Best Practice of Healthy Living. The current six Dermatology-specific measures are in Communication and Coordination and Resource Use. (Submitted by: American Academy of Dermatology)
This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

We support the inclusion of this measure that is part of the American Academy of Dermatology (AAD) strategy to provide a comprehensive quality approach for patients with skin cancer. Including this measure will further expand performance measurement through the entire skin cancer care process. Each has been developed to address either a rate limiting step to quality care or a significant waste/overuse issue. This is a measure of care for basal cell carcinoma, the most common form of skin cancer, affecting more than 2 million people each year. The measure will add value to the MIPS measure set because it has the potential to improve patient outcomes, ensure appropriate resource utilization and reduce overall healthcare costs by reducing inappropriate use of Mohs surgery. This measure also fills a critical program need for measures of skin care. There are only 6 dermatology-specific measures in PQRS and none on basal or squamous cell carcinoma. Adding this measure to PQRS will help dermatologists, particularly skin cancer specialists, continue to report successfully, avoid penalties for under-reporting for programs such as PQRS and the Value Based Payment Modifier, and more importantly, to contribute to the quality of patient care and the performance goals of CMS. (Submitted by: American Academy of Dermatology)
ASPS is pleased to see meaningful and relevant measures for plastic surgeons in the MIPS program. Going forward, ASPS wishes to continue to see more relevant measures for specialties and surgical specialties. (Submitted by: American Society of Plastic Surgeons)
This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American College of Mohs Surgery (ACMS) represents more than 1,300 Mohs micrographic surgeons, the vast majority who have successfully completed extensive fellowship-training in Mohs micrographic surgery (MMS) following their dermatology residency training. Today, we write in support of Measure 178, Use of Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients, which is an important measure of care for basal cell carcinoma, the most common skin cancer. This measure stems from the American Academy of Dermatology (AAD) Mohs Micrographic Surgery (MMS) Appropriate Use Criteria (AUC), which considered the expertise of more than 75 physicians, including ACMS Fellows, and followed the rigorous Appropriateness Method developed by RAND/UCLA. This measure is appropriate for use in the current PQRS program, as well as the future MIPS program. (Submitted by: The American College of Mohs Surgery)

We support the inclusion of this measure that is part of the American Academy of Dermatology (AAD) strategy to provide a comprehensive quality approach for patients with skin cancer. Including this measure will further expand performance measurement through the entire skin cancer care process. Each has been developed to address either a rate limiting step to quality care or a significant waste/overuse issue. This is an important measure of care for Squamous Cell Carcinoma, a skin cancer affecting around 700,000 people a year. The measure will add value to the MIPS measure set because it has the potential to improve patient outcomes, ensure appropriate resource utilization and reduce overall healthcare costs by reducing inappropriate use of Mohs surgery. This measure also fills a critical program need for measures of skin care. There are only 6 dermatology-specific measures in PQRS and none on basal or squamous cell carcinoma. Adding this measure to PQRS will help dermatologists, particularly skin cancer specialists, continue to report successfully, avoid penalties for under-reporting for programs such as PQRS and the Value Based Payment Modifier, and more importantly, to contribute to the quality of patient care and the performance goals of CMS. (Submitted by: American Academy of Dermatology)
ASPS is pleased to see meaningful and relevant measures for plastic surgeons in the MIPS program. Going forward, ASPS wishes to continue to see more relevant measures for specialties and surgical specialties. (Submitted by: American Society of Plastic Surgeons)
This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American College of Mohs Surgery (ACMS) represents more than 1,300 Mohs micrographic surgeons, the vast majority who have successfully completed extensive fellowship-training in Mohs micrographic surgery (MMS) following their dermatology residency training. Today, we write in support of Measure 179, Use of Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk, is an important measure of care for Squamous Cell Carcinoma, the second most common skin cancer. This measure stems from the American Academy of Dermatology (AAD) Mohs Micrographic Surgery (MMS) Appropriate Use Criteria (AUC), which considered the expertise of more than 75 physicians, including ACMS Fellows, and followed the rigorous Appropriateness Method developed by RAND/UCLA. This measure is appropriate for use in the current PQRS program, as well as the future MIPS program. (Submitted by: The American College of Mohs Surgery)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
While ASGE finds the inclusion of surveillance measures in public reporting programs worthy of exploration, this measure concept currently lacks sufficient evidence to show importance to measure and variation in performance. Further, as currently specified, this measure would not deter overutilization. (Submitted by: American Society for Gastrointestinal Endoscopy)
Surveillance is an important tool in the management of Barrett’s as studies support that early detection and treatment of dysplastic Barrett’s lesions can reduce the incidence of esophageal adenocarcinoma and is consistent with longstanding AGA guidelines as noted in the Measure Rationale. However, this measure has never been submitted to NQF for evaluation/endorsement. Thus, we would support inclusion of this measure for consideration in MIPS – only pending future NQF-endorsement. If selected for use, given the rapid pace of innovation in this area, we encourage MAP to monitor CMS’ use of this measure to ensure that potential future FDA-approved technologies that advance medicine and may further improve patient adherence are considered in the numerator. (Submitted by: AdvaMed)
Surveillance is an important tool in the management of Barrett’s as studies support that early detection and treatment of dysplastic Barrett’s lesions can reduce the incidence of esophageal adenocarcinoma and is consistent with longstanding AGA guidelines as noted in the Measure Rationale. Thus, we support inclusion of this measure for consideration in MIPS. However, given the rapid pace of innovation in this area, we encourage MAP to monitor CMS’ use of this measure to ensure that potential future FDA-approved technologies that advance medicine and may further improve patient adherence are considered in the numerator. (Submitted by: Medtronic)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
ASGE does not support advancement of this measure concept as other equally effective treatments are available for patients with esophageal varices. AASLD guidelines leave the treatment option to the discretion of the provider. Further, 25% of patients taking beta blockers have side effects precluding many patients from taking them. (Submitted by: American Society for Gastrointestinal Endoscopy)
This measure is currently being field tested,has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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. (Submitted by: American Society for Gastrointestinal Endoscopy)
Inclusion of these measures will build on existing immunization-related measures currently used in the Physician Quality Reporting System to help ensure that Medicare beneficiaries benefit from these important vaccinations. (Submitted by: Trust for America's Health)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
On behalf of Hep B United, we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. Hep B United is a national coalition comprised of 30 community-based coalitions and national organizations with a reach of over 4 million, to address and eliminate hepatitis B, the leading cause of liver cancer and a major health disparity among Asian Americans and Pacific Islanders. Our collective goals are to raise the profile of hepatitis B and liver cancer as an urgent public health priority, increase hepatitis B testing and vaccination, and improve access to care and treatment for individuals living with hepatitis B. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with our coalition’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons athigh risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact Hep B United at kate.moraras@hepb.org with any questions or further discussion on our comments. (Submitted by: Hep B United)
December 7, 2015 RE: 2015 Measures under Consideration by the National Quality Forum (NQF) Measure Applications Partnership (MAP) On behalf of the Hepatitis B Foundation (HBF), we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. The Hepatitis B Foundation is the only national nonprofit organization solely dedicated to finding a cure for hepatitis B and improving the quality of life for those affected worldwide through research, education and patient advocacy. Our commitment includes funding focused research, promoting disease awareness, supporting immunization and treatment initiatives, and serving as the primary source of information for patients and their families, the medical and scientific community, and the general public. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: -MUC15-210: Hepatitis A vaccination for patients with cirrhosis -MUC15-211: Hepatitis B vaccination for patients with cirrhosis -MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B -MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C -MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with HBF’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact the Hepatitis B Foundation Executive Director at joan.block@hepb.org with any questions or further discussion on our comments. Sincerely, Joan Block, Executive Director Hepatitis B Foundation (Submitted by: Hepatitis B Foundation)
On behalf of the Association of Asian Pacific Community Health Organizations (AAPCHO), we appreciate the opportunity to provide comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. AAPCHO is a national not-for-profit association of 35 community-based health care organizations, 29 of which are Federally Qualified Health Centers (FQHCs). AAPCHO members are dedicated to promoting advocacy, collaboration, and leadership to improve the health status and access of medically underserved AA&NHOPIs in the U.S., its territories, and its freely associated states. AAPCHO’s members provide linguistically and culturally competent care to millions of vulnerable Asian Americans, Native Hawaiians, and Other Pacific Islanders (AA & NHOPIs). Many of our members serve a higher than average percentage of patients with hepatitis B and C, as both diseases have high prevalence rates in Asian Americans and Pacific Islanders. Because of the high rates of hepatitis B found in many of our member centers, AAPCHO co-founded Hep B United, a national coalition of over 30 local coalitions working to address hepatitis B through education, screening, vaccination, and linkage-to-care efforts. As such, we strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease. We particularly support the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with Hep B United and AAPCHO’s priorities to increase hepatitis B testing and vaccination in the high-risk populations that AAPCHO members serve, and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. We respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination to screen individuals at risk for hepatitis B, matching the U.S. Preventive Services Task Force’s “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. AAPCHO greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please contact Isha Weerasinghe, AAPCHO’s Director of Policy and Advocacy at isha@aapcho.org if you have any questions or comments. Thank you, Jeffrey Caballero, MPH Executive Director (Submitted by: Association of Asian Pacific Community Health Organizations)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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. (Submitted by: American Society for Gastrointestinal Endoscopy)
Inclusion of these measures will build on existing immunization-related measures currently used in the Physician Quality Reporting System to help ensure that Medicare beneficiaries benefit from these important vaccinations. (Submitted by: Trust for America's Health)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
On behalf of Hep B United, we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. Hep B United is a national coalition comprised of 30 community-based coalitions and national organizations with a reach of over 4 million, to address and eliminate hepatitis B, the leading cause of liver cancer and a major health disparity among Asian Americans and Pacific Islanders. Our collective goals are to raise the profile of hepatitis B and liver cancer as an urgent public health priority, increase hepatitis B testing and vaccination, and improve access to care and treatment for individuals living with hepatitis B. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with our coalition’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact Hep B United at kate.moraras@hepb.org with any questions or further discussion on our comments. (Submitted by: Hep B United)
December 7, 2015 RE: 2015 Measures under Consideration by the National Quality Forum (NQF) Measure Applications Partnership (MAP) On behalf of the Hepatitis B Foundation (HBF), we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. The Hepatitis B Foundation is the only national nonprofit organization solely dedicated to finding a cure for hepatitis B and improving the quality of life for those affected worldwide through research, education and patient advocacy. Our commitment includes funding focused research, promoting disease awareness, supporting immunization and treatment initiatives, and serving as the primary source of information for patients and their families, the medical and scientific community, and the general public. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: -MUC15-210: Hepatitis A vaccination for patients with cirrhosis -MUC15-211: Hepatitis B vaccination for patients with cirrhosis -MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B -MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C -MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with HBF’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact the Hepatitis B Foundation Executive Director at joan.block@hepb.org with any questions or further discussion on our comments. Sincerely, Joan Block, Executive Director Hepatitis B Foundation (Submitted by: Hepatitis B Foundation)
On behalf of the Association of Asian Pacific Community Health Organizations (AAPCHO), we appreciate the opportunity to provide comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. AAPCHO is a national not-for-profit association of 35 community-based health care organizations, 29 of which are Federally Qualified Health Centers (FQHCs). AAPCHO members are dedicated to promoting advocacy, collaboration, and leadership to improve the health status and access of medically underserved AA&NHOPIs in the U.S., its territories, and its freely associated states. AAPCHO’s members provide linguistically and culturally competent care to millions of vulnerable Asian Americans, Native Hawaiians, and Other Pacific Islanders (AA & NHOPIs). Many of our members serve a higher than average percentage of patients with hepatitis B and C, as both diseases have high prevalence rates in Asian Americans and Pacific Islanders. Because of the high rates of hepatitis B found in many of our member centers, AAPCHO co-founded Hep B United, a national coalition of over 30 local coalitions working to address hepatitis B through education, screening, vaccination, and linkage-to-care efforts. As such, we strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease. We particularly support the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with Hep B United and AAPCHO’s priorities to increase hepatitis B testing and vaccination in the high-risk populations that AAPCHO members serve, and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. We respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination to screen individuals at risk for hepatitis B, matching the U.S. Preventive Services Task Force’s “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. AAPCHO greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please contact Isha Weerasinghe, AAPCHO’s Director of Policy and Advocacy at isha@aapcho.org if you have any questions or comments. Thank you, Jeffrey Caballero, MPH Executive Director (Submitted by: Association of Asian Pacific Community Health Organizations)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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. (Submitted by: American Society for Gastrointestinal Endoscopy)
AdvaMed fully supports quality care for patients with Crohn’s Disease; however, we do not believe that this measure is appropriate for consideration in MIPS. In addition, this measure has never been submitted to NQF and thus is not NQF-endorsed. Colonoscopy is the only surveillance modality included in the measure numerator. However, in addition to colonoscopy, there are other diagnostics that can also be used for surveillance of Crohn’s Disease. We encourage MAP to seek inclusion of other guideline-supported technologies in the measure numerator before CMS considers this measure for use in MIPS or other quality programs. (Submitted by: AdvaMed)
Medtronic fully supports quality care for patients with Crohn’s Disease; however, we do not believe that this measure is appropriate for consideration in MIPS. Colonoscopy is the only surveillance modality included in the measure numerator. However, in addition to colonoscopy, there are other diagnostics that can also be used for surveillance of Crohn’s Disease. We encourage MAP to seek inclusion of other guideline-supported technologies in the measure numerator before CMS considers this measure for use in MIPS or other quality programs. (Submitted by: Medtronic)

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

We support the inclusion of this measure that is part of the American Academy of Dermatology (AAD) strategy to provide a comprehensive quality approach for patients with skin cancer. Including this measure will further expand performance measurement through the entire skin cancer care process. Each has been developed to address either a rate limiting step to quality care or a significant waste/overuse issue. This is an important measure of care for basal or squamous cell carcinoma, the most common types of skin cancer, affecting more than 3 million people each year. This measure will add value to the MIPS measure set because it addresses the fragmented communication between physicians and patients about biopsy results. This measure encourages timely notification to patients of the final biopsy results to ensure effective treatment. Lack of timely delivery can increase the cost of medical care, error and the anxiety the patient experiences in waiting for results. This measure also fills a critical program need for measures of skin care as there are only 6 dermatology-specific measures in PQRS and none for care for basal or squamous cell carcinoma. Adding this measure to PQRS will help dermatologists, continue to report successfully, avoid penalties for under-reporting for programs such as PQRS and the Value Based Payment Modifier, and more importantly, to contribute to the quality of patient care and the performance goals of CMS. (Submitted by: American Academy of Dermatology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

We support the inclusion of this measure that is part of the American Academy of Dermatology (AAD) strategy to provide a comprehensive quality approach for patients with skin cancer. Including this measure will further expand performance measurement through the entire skin cancer care process. Each has been developed to address either a rate limiting step to quality care or a significant waste/overuse issue. This is an important measure of care for basal or squamous cell carcinoma, the most common types of skin cancer, affecting more than 3 million people each year. This measure will add value to the MIPS measure set because it addresses the fragmented communication between pathologists and physicians about patient outcomes. Effective communication through the biopsy report between the two practitioners is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery of biopsy results can increase the cost of medical care, error and the anxiety the patient experiences in waiting for results. This measure also fills a critical program need for measures of skin care as there are only 6 dermatology-specific measures in PQRS, none for care for basal or squamous cell carcinoma and only one for dermatopathologists. Adding this measure to PQRS will help dermatologists, particularly dermatopathologists, report successfully, avoid penalties for under-reporting for programs such as PQRS and the Value Based Payment Modifier, and more importantly, to contribute to the quality of patient care and the performance goals of CMS. (Submitted by: American Academy of Dermatology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
At this time, the College of American Pathologists (CAP) cannot support MUC 216: Biopsy Reporting Time – Pathologist to Clinician. While we believe that timely communication of laboratory results is important to patient satisfaction, we do not think that this measure is clinically relevant or a fair representation of quality. The measure may have unintended consequences if providers aim to meet the stated specimen turnaround time but do so at the detriment of complete reports. Further, the rationale for the measure is that there is fragmented communication between pathologists and physicians about patient outcomes. We agree that timely communication is important to patient satisfaction, but are worried that a focus on turn-around time may increase fragmentation. However, in many cases the challenge exists in communication between electronic or paper health records and not necessarily in the actual specimen result turnaround time. For these reasons, we are unable to provide our support for this measure. (Submitted by: The College of American Pathologists)
Pathology has very few indicators and this appears to be a reasonable one. The objectives align with better patient care outcomes, better communication among providers, and less errors due to incomplete information in the hands of the treating physicians. Most lab information systems should be able to generate these data without undue programming issues. There is no equivalent measure in the current set. (Submitted by: American Society of Dermatopathology)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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. (Submitted by: American Society for Gastrointestinal Endoscopy)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
On behalf of Hep B United, we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. Hep B United is a national coalition comprised of 30 community-based coalitions and national organizations with a reach of over 4 million, to address and eliminate hepatitis B, the leading cause of liver cancer and a major health disparity among Asian Americans and Pacific Islanders. Our collective goals are to raise the profile of hepatitis B and liver cancer as an urgent public health priority, increase hepatitis B testing and vaccination, and improve access to care and treatment for individuals living with hepatitis B. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with our coalition’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact Hep B United at kate.moraras@hepb.org with any questions or further discussion on our comments. (Submitted by: Hep B United)
December 7, 2015 RE: 2015 Measures under Consideration by the National Quality Forum (NQF) Measure Applications Partnership (MAP) On behalf of the Hepatitis B Foundation (HBF), we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. The Hepatitis B Foundation is the only national nonprofit organization solely dedicated to finding a cure for hepatitis B and improving the quality of life for those affected worldwide through research, education and patient advocacy. Our commitment includes funding focused research, promoting disease awareness, supporting immunization and treatment initiatives, and serving as the primary source of information for patients and their families, the medical and scientific community, and the general public. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: ? MUC15-210: Hepatitis A vaccination for patients with cirrhosis -MUC15-211: Hepatitis B vaccination for patients with cirrhosis -MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B -MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C -MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with HBF’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact the Hepatitis B Foundation Executive Director at joan.block@hepb.org with any questions or further discussion on our comments. Sincerely, Joan Block, Executive Director Hepatitis B Foundation (Submitted by: Hepatitis B Foundation)
RE: 2015 Measures under Consideration As participants in the Adult Vaccine Access Coalition (AVAC), we are grateful for the opportunity to offer our comments on Measures under Consideration by the Measure Applications Partnership (MAP) at the National Quality Forum (NQF). AVAC consists of more than 40 organizational leaders in health and public health that are committed to tackling the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our mission is informed by a growing body of scientific and empirical evidence in support of the benefits immunizations provide by improving health, protecting lives against a variety of debilitating and potentially deadly conditions and saving costs to the healthcare system and to society as a whole. We appreciate NQF’s leadership in the area of adult vaccines, particularly the August 2014 report, "Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations." One of AVAC’s key coalition priorities is to advocate for federal benchmarks and measures to encourage health plans to track, report and achieve increased adult immunization rates. We believe the vaccine related measures under MAP consideration make progress toward closing the measure gaps identified in the report: First, we commend NQF for considering process measures for Medicare beneficiaries with liver diseases, including Hepatitis A and Hepatitis B measures for cirrhosis patients (MUC15-210 and MUC15-211) and Hep B vaccination for patients with chronic Hepatitis C (MUC15-220), as well as a flu vaccine measure for end stage renal disease (ESRD) patients (MUC15-761). Our coalition strongly believes that consistent and improved access to the range of Advisory Committee on Immunization Practices (ACIP) recommended vaccines for adults will result in improved health outcomes and better quality of life for Medicare beneficiaries. As such, the vaccine process measures under consideration by NQF for the MIPS build upon core immunization measures currently employed by CMS under the Physician Quality Reporting System (PQRS). We urge NQF to continue its work with CMS to ensure that the core set of immunization process measures included in the Medicare Incentive Payment System (MIPS) are up-to-date and reflect current ACIP recommendations. We also encourage NQF to continue to identify, develop and test immunization process measures that will improve the overall health for Medicare patients living with other chronic conditions such as heart disease and diabetes under the new MIPS. Additionally, we support the inclusion of MUC15-1132, Percent of Skilled Nursing Facility Residents Who Were Assessed and Appropriately Given the Influenza Vaccine. This important process measure complements and reinforces CMS’ efforts to improve education and awareness of long-term care facility residents and their representatives of the risks and benefits of immunization against a variety of preventable conditions . Long-term care facility residents, especially those with chronic conditions, are at increased risk for influenza and disproportionately suffer from influenza-related complications such as pneumonia, making immunization particularly important for patient health and safety. We would also encourage NQF to prioritize the development of an updated pneumococcal immunization measures that reflects the current Advisory Committee for Immunization Practice (ACIP) recommendations for PCV13 and PPSV23 vaccination in adults age 65 and older as well as at risk adults ages 19-64 for use across various health care settings. The Health and Well-Being Committee for the National Quality Forum (NQF) recently proposed standards specifications for pneumococcal measures in order to better align measures across healthcare settings and to bring measures in accordance with ACIP recommendations. AVAC encourages NQF to work with CMS toward that end since it reflects CMS' broader goals around quality measure alignment. Lastly, we would ask NQF to further coordinate with CMS and prioritize the identification, development testing and endorsement of vaccine measures for application by other CMS programs in addition to the ones listed for 2015. For example, the recently finalized CMS rule on Medicare home health value-based purchasing includes a new measure entitled, “Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?) . Zoster vaccination measurement was identified as an age-specific gap priority in NQF’s August 2014 adult immunization measure gap report . Shingles affects a million Americans each year, half of whom are adults age 60 and older. This extremely debilitating condition takes a significant toll on Medicare beneficiaries’ health and quality of life and also costs millions in health care dollars annually. Thank you for your work to advance health and wellbeing through your stewardship and leadership in quality measure identification, development and deployment. We greatly appreciate the opportunity to share our perspective on the vaccine related process measures currently under consideration. Should you have any questions or would like to discuss our comments or adult immunization issues, please contact the AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org. Sincerely, American College of Preventive Medicine Asian & Pacific Islander American Health Forum Association for Professionals in Infection Control and Epidemiology GSK Hepatitis B Foundation Hep B United National Association of County and City Health Officials National Alliance of State & Territorial AIDS Directors National Foundation for Infectious Diseases National Viral Hepatitis Roundtable Novavax Sanofi Pasteur The Gerontological Society of America Trust for America’s Health (Submitted by: Adult Vaccine Access Coalition)
On behalf of the Association of Asian Pacific Community Health Organizations (AAPCHO), we appreciate the opportunity to provide comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. AAPCHO is a national not-for-profit association of 35 community-based health care organizations, 29 of which are Federally Qualified Health Centers (FQHCs). AAPCHO members are dedicated to promoting advocacy, collaboration, and leadership to improve the health status and access of medically underserved AA&NHOPIs in the U.S., its territories, and its freely associated states. AAPCHO’s members provide linguistically and culturally competent care to millions of vulnerable Asian Americans, Native Hawaiians, and Other Pacific Islanders (AA & NHOPIs). Many of our members serve a higher than average percentage of patients with hepatitis B and C, as both diseases have high prevalence rates in Asian Americans and Pacific Islanders. Because of the high rates of hepatitis B found in many of our member centers, AAPCHO co-founded Hep B United, a national coalition of over 30 local coalitions working to address hepatitis B through education, screening, vaccination, and linkage-to-care efforts. As such, we strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease. We particularly support the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with Hep B United and AAPCHO’s priorities to increase hepatitis B testing and vaccination in the high-risk populations that AAPCHO members serve, and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. We respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination to screen individuals at risk for hepatitis B, matching the U.S. Preventive Services Task Force’s “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. AAPCHO greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please contact Isha Weerasinghe, AAPCHO’s Director of Policy and Advocacy at isha@aapcho.org if you have any questions or comments. Thank you, Jeffrey Caballero, MPH Executive Director (Submitted by: Association of Asian Pacific Community Health Organizations)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
Inclusion of these measures will build on existing immunization-related measures currently used in the Physician Quality Reporting System to help ensure that Medicare beneficiaries benefit from these important vaccinations. (Submitted by: Trust for America's Health)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
On behalf of Hep B United, we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. Hep B United is a national coalition comprised of 30 community-based coalitions and national organizations with a reach of over 4 million, to address and eliminate hepatitis B, the leading cause of liver cancer and a major health disparity among Asian Americans and Pacific Islanders. Our collective goals are to raise the profile of hepatitis B and liver cancer as an urgent public health priority, increase hepatitis B testing and vaccination, and improve access to care and treatment for individuals living with hepatitis B. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with our coalition’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact Hep B United at kate.moraras@hepb.org with any questions or further discussion on our comments. (Submitted by: Hep B United)
December 7, 2015 RE: 2015 Measures under Consideration by the National Quality Forum (NQF) Measure Applications Partnership (MAP) On behalf of the Hepatitis B Foundation (HBF), we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. The Hepatitis B Foundation is the only national nonprofit organization solely dedicated to finding a cure for hepatitis B and improving the quality of life for those affected worldwide through research, education and patient advocacy. Our commitment includes funding focused research, promoting disease awareness, supporting immunization and treatment initiatives, and serving as the primary source of information for patients and their families, the medical and scientific community, and the general public. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: -MUC15-210: Hepatitis A vaccination for patients with cirrhosis -MUC15-211: Hepatitis B vaccination for patients with cirrhosis -MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B -MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C -MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with HBF’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact the Hepatitis B Foundation Executive Director at joan.block@hepb.org with any questions or further discussion on our comments. Sincerely, Joan Block, Executive Director Hepatitis B Foundation (Submitted by: Hepatitis B Foundation)
On behalf of the Association of Asian Pacific Community Health Organizations (AAPCHO), we appreciate the opportunity to provide comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. AAPCHO is a national not-for-profit association of 35 community-based health care organizations, 29 of which are Federally Qualified Health Centers (FQHCs). AAPCHO members are dedicated to promoting advocacy, collaboration, and leadership to improve the health status and access of medically underserved AA&NHOPIs in the U.S., its territories, and its freely associated states. AAPCHO’s members provide linguistically and culturally competent care to millions of vulnerable Asian Americans, Native Hawaiians, and Other Pacific Islanders (AA & NHOPIs). Many of our members serve a higher than average percentage of patients with hepatitis B and C, as both diseases have high prevalence rates in Asian Americans and Pacific Islanders. Because of the high rates of hepatitis B found in many of our member centers, AAPCHO co-founded Hep B United, a national coalition of over 30 local coalitions working to address hepatitis B through education, screening, vaccination, and linkage-to-care efforts. As such, we strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease. We particularly support the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with Hep B United and AAPCHO’s priorities to increase hepatitis B testing and vaccination in the high-risk populations that AAPCHO members serve, and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. We respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination to screen individuals at risk for hepatitis B, matching the U.S. Preventive Services Task Force’s “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. AAPCHO greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please contact Isha Weerasinghe, AAPCHO’s Director of Policy and Advocacy at isha@aapcho.org if you have any questions or comments. Thank you, Jeffrey Caballero, MPH Executive Director (Submitted by: Association of Asian Pacific Community Health Organizations)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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 Ulcerative Colitis are based on how long the patient has had the disease. (Submitted by: American Society for Gastrointestinal Endoscopy)
AdvaMed fully supports quality care for patients with Ulcerative colitis; however, we do not believe that this measure is appropriate for consideration in MIPS. In addition, this measure has never been submitted to NQF and thus is not NQF-endorsed. Colonoscopy is the only surveillance modality included in the measure numerator. In addition to colonoscopy, there are other diagnostics that can also be used for surveillance of Ulcerative colitis. We encourage MAP to seek inclusion of other guideline-supported technologies in the measure numerator before CMS considers this measure for use in MIPS or other quality programs. (Submitted by: AdvaMed)
Medtronic fully supports quality care for patients with Ulcerative colitis; however, we do not believe that this measure is appropriate for consideration in MIPS. Colonoscopy is the only surveillance modality included in the measure numerator. In addition to colonoscopy, there are other diagnostics that can also be used for surveillance of Ulcerative colitis. We encourage MAP to seek inclusion of other guideline-supported technologies in the measure numerator before CMS considers this measure for use in MIPS or other quality programs. (Submitted by: Medtronic)

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

ASGE supports the advancement of this measure. (Submitted by: American Society for Gastrointestinal Endoscopy)
We support the inclusion of this measure, reflecting effective treatment of Hepatitis C (HCV), in the new Medicare Merit-Based Incentive Payment System (MIPS). The past several years have seen significant changes in the public health response to the challenge of HCV. Recognizing that “Baby Boomers” born between 1945 and 1965 account for three-quarters of the 3.2 million people in the U.S. infected with HCV, the Centers for Disease Control and Prevention (CDC) in 2012 began recommending one-time screening of this entire cohort. In the meantime, this population has begun aging into Medicare. In addition, the heroin epidemic and heightened detection efforts have contributed to new acute hepatitis C infections increasing by 151.5 percent in reported cases from 2010 to 2013. And, over the past several years, newer and more effective HCV treatments have become available, leading to far higher rates of cure with fewer side effects, ultimately decreasing the risk of serious outcomes such as liver cancer and death. To address this epidemic, it is vitally important that increased screening efforts and improved treatments translate into improved health for patients, and this measure will help support that goal. (Submitted by: Trust for America's Health)
Unclear why the period of measurement is 11 weeks, rather than 12 weeks. (Submitted by: California Department of Public Health)
On behalf of Hep B United, we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. Hep B United is a national coalition comprised of 30 community-based coalitions and national organizations with a reach of over 4 million, to address and eliminate hepatitis B, the leading cause of liver cancer and a major health disparity among Asian Americans and Pacific Islanders. Our collective goals are to raise the profile of hepatitis B and liver cancer as an urgent public health priority, increase hepatitis B testing and vaccination, and improve access to care and treatment for individuals living with hepatitis B. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with our coalition’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact Hep B United at kate.moraras@hepb.org with any questions or further discussion on our comments. (Submitted by: Hep B United)
December 7, 2015 RE: 2015 Measures under Consideration by the National Quality Forum (NQF) Measure Applications Partnership (MAP) On behalf of the Hepatitis B Foundation (HBF), we appreciate the opportunity to offer comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. The Hepatitis B Foundation is the only national nonprofit organization solely dedicated to finding a cure for hepatitis B and improving the quality of life for those affected worldwide through research, education and patient advocacy. Our commitment includes funding focused research, promoting disease awareness, supporting immunization and treatment initiatives, and serving as the primary source of information for patients and their families, the medical and scientific community, and the general public. We strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease, particularly the following process and outcome measures under the Merit-Based Incentive Payment System program: -MUC15-210: Hepatitis A vaccination for patients with cirrhosis -MUC15-211: Hepatitis B vaccination for patients with cirrhosis -MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B -MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C -MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with HBF’s priorities to increase hepatitis B testing and vaccination in high-risk populations and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. Additionally, we respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination for this service, to match the U.S. Preventive Services Task Force “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. HBU greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please do not hesitate to contact the Hepatitis B Foundation Executive Director at joan.block@hepb.org with any questions or further discussion on our comments. Sincerely, Joan Block, Executive Director Hepatitis B Foundation (Submitted by: Hepatitis B Foundation)
On behalf of the Association of Asian Pacific Community Health Organizations (AAPCHO), we appreciate the opportunity to provide comments on the 2015 Measures Under Consideration by the Measures Application Partnership at the National Quality Forum. AAPCHO is a national not-for-profit association of 35 community-based health care organizations, 29 of which are Federally Qualified Health Centers (FQHCs). AAPCHO members are dedicated to promoting advocacy, collaboration, and leadership to improve the health status and access of medically underserved AA&NHOPIs in the U.S., its territories, and its freely associated states. AAPCHO’s members provide linguistically and culturally competent care to millions of vulnerable Asian Americans, Native Hawaiians, and Other Pacific Islanders (AA & NHOPIs). Many of our members serve a higher than average percentage of patients with hepatitis B and C, as both diseases have high prevalence rates in Asian Americans and Pacific Islanders. Because of the high rates of hepatitis B found in many of our member centers, AAPCHO co-founded Hep B United, a national coalition of over 30 local coalitions working to address hepatitis B through education, screening, vaccination, and linkage-to-care efforts. As such, we strongly support the measures under consideration for Medicare beneficiaries living with chronic viral hepatitis and liver disease. We particularly support the following process and outcome measures under the Merit-Based Incentive Payment System program: • MUC15-210: Hepatitis A vaccination for patients with cirrhosis • MUC15-211: Hepatitis B vaccination for patients with cirrhosis • MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B • MUC15-220: Hepatitis B vaccination for patients with Chronic Hepatitis C • MUC15-229: Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) These measures align with Hep B United and AAPCHO’s priorities to increase hepatitis B testing and vaccination in the high-risk populations that AAPCHO members serve, and improve access to care and treatment for individuals living with chronic hepatitis B to prevent end-stage liver disease and liver cancer. Of the identified and reported cases of hepatitis B virus infection in the United States between 2007 and 2012, 15.6% were over the age of 65 and part of the Medicare covered population. It is vital that seniors diagnosed with chronic hepatitis B be linked to care and monitored for hepatocellular carcinoma, thus, we particularly commend the inclusion of MUC15-217: Screening for Hepatoma in patients with Chronic Hepatitis B. We respectfully take this opportunity to encourage the Centers for Medicare and Medicaid (CMS) to consider measures for screening for hepatitis B virus infection for those individuals at high risk. An estimated 67% of individuals do not know they have chronic hepatitis B including those who are part of the Medicare covered population. It is imperative that CMS consider a National Coverage Determination to screen individuals at risk for hepatitis B, matching the U.S. Preventive Services Task Force’s “B” grade recommendation for hepatitis B screening in persons at high risk for infection. We thank the NQF Measures Application Partnership for your work and consideration of our comments. AAPCHO greatly appreciates this opportunity to provide input to the 2015 Measures Under Consideration that impact the health of Medicare beneficiaries living with chronic viral hepatitis and liver disease. Please contact Isha Weerasinghe, AAPCHO’s Director of Policy and Advocacy at isha@aapcho.org if you have any questions or comments. Thank you, Jeffrey Caballero, MPH Executive Director (Submitted by: Association of Asian Pacific Community Health Organizations)

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

We support the inclusion of HIV screening for patients with STDs in MIPS. In general, CDC recommends HIV testing at each new visit where a patient either requests STI testing or tests positive for an STI , among other criteria. There is a distinct need to encourage providers to test among Medicare beneficiaries, especially those at high risk including those with STIs. While many older people are sexually active, they are less likely to be tested for HIV than younger populations, and, if diagnosed, they are likely to be diagnosed later in the course of the disease. This measure could encourage an improved response to HIV among both senior citizens and adults with disabilities enrolled in Medicare. (Submitted by: Trust for America's Health)
While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: California Department of Public Health)
The American College of Obstetricians and Gynecologists supports the measure concept for adult women. Adolescent confidentiality, especially in the realm of reproductive and sexual health care, is of utmost importance to obstetricians and gynecologists. Measurement of adolescents when many providers may be referring to Title X clinics or other providers to maintain confidentiality because of a health insurance plan's Explanation of Benefits. With the Affordable Care Act, these workarounds for confidentiality may continue through 26 years of age. We do not believe health care providers will be measured accurately or fairly in the adolescent (through 26) population. Please see our Committee Opinion 599 (MAY 2014) for more information. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescent-Confidentiality-and-Electronic-Health-Records (Submitted by: American College of Obstetricians and Gynecologists)

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

While AGA agrees that the intent of this measure has some merit, AGA does not at this time support inclusion of this measure on the list of measures to be finalized for PQRS implementation (Submitted by: American Gastroenterological Association)
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 cirrhotics and within a year if they are decompensated. (Submitted by: American Society for Gastrointestinal Endoscopy)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This is a question regarding portal hypertension. I am not sure of the value of endoscopy surveys of all patients with cirrhosis so I have no comments on the value of this measure. (Submitted by: Society of Interventional Radiology)

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

We support the composite approach with this measure and the description of the measure with four criteria required to achieve compliance. We cannot support the measure as it has been revised from the original version in which cholesterol risk was addressed by the criteria of ‘LDL less than 100’ as part of the numerator. The rationale for the removal of the LDL level was provided in the NQF May 2014 update of the measure: the removal was based on the 2013 AHA/ACC guidelines and the MN Community indicated that it intended to revise the measure in 2016 to be more consistent with the 2013 guidelines. This measure had been introduced by the Wisconsin Collaborative for Healthcare Quality (WCHQ) with the addition of ‘statin use” as the 4th criteria. We have two objections. A. We believe the retirement of the LDL-C criteria was based upon a misunderstanding of the ACC/AHA Guidelines and is not supported by recent evidence or recommendations from other medical societies. B. The requirement for use of a statin without regard for the matching the patient’s level of risk with the dosing is not consistent with national guidelines and will not achieve optimal desired reduction in ASCVD events. A: LDL-C Criteria is an appropriate intermediate outcome measurement First, Dr. Knowles and Dr. Stone’s paper, “Familial Hypercholesterolemia and the 2013 American College of Cardiology/ American Heart Association Guidelines: Myths, Oversimplification and Misinterpretation versus Facts” American Journal of Cardiology, Aug. 1, 2015 Vol. 116, Issue 3, pgs 481-484 (http://www.ajconline.org/article/S0002-9149(15)01260-6/abstract) established the import of LDLs in the management of ASCVD risk in all patients, highlighting the recommendation in the guidelines and the need for periodic monitoring of the LDL-C level to determine adequacy of response to therapy and adherence and the need to adjust the treatment regimen. It also pointed out that statins alone do not provide the outcomes needed to protect FH and high risk patients. This is further supported by the recommendations and guidelines published by NLA, AACE and other societies. LDL levels are critical to achieving intermediate and long term outcomes and the totality of evidence does not support the omission of the LDL-C as a threshold or target. Second, although specific LDL-C treatment goals are not recommended in the guideline, the statin intensity recommendations are benchmarked against expected LDL-C reductions in those initially being started on statins (i.e. >50% high; 30% to <50% moderate) and includes guidance for LDL-C levels for all patients. Considering heterogenic response in the natural setting with statin tolerability, adherence, etc., measuring LDL-C (either directly or calculated) is necessary to confirm patients are achieving treatment goals. To this end, the guideline recommends monitoring response with lipid panels every 3 to 12 months (IA recommendation) and appropriate treatment adjustment). 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, available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.citation. Third, we do not believe the focus on choice of therapy to the exclusion of LDL levels is consistent with the guidelines and their intent. The charge of CMS is to address treatment of blood cholesterol levels to reduce ASCVD risk. They have provided an ASCVD risk calculator to determine a patient’s initial risk and reduction in risk based on improved parameters. The parameters used in calculating a person’s risk do not include use of statins or any other reference to treatment methods. The parameters are clinical: they include the patient’s LDL and HDL level. We cannot avoid measuring and considering the absolute LDL if the intent is to reduce risk and ASCVD outcomes. In addition, ACC/AHA has recognized that there has been some confusion arising from the language used in the 2013 Guidelines and they have established committees to address, refine or modify their recommendations to provide additional clarity. We believe that the issue of LDL-C thresholds may be part of this conversation and that any proposed changes to measures should be delayed until the ACC/AHA have clarified their position. Fourth, we believe it is not warranted to change LDL-C quality measures based on a single guideline; and a guideline that is not endorsed by other key expert groups and societies dedicated to diseases of metabolism, including the National Lipid Association (NLA), American Academy of Clinical Endocrinologists (AACE), and American Diabetes Association (ADA). AACE and ADA have separate cholesterol guidelines that currently recommend LDL-C <100 mg/dL in high risk patients including those with diabetes and those with prior ischemic events. Fifth, the measure as written is contrary to CMS objectives to measure outcomes. New legislation directed CMS to develop a strategic plan to integrate quality of care into Pay for Performance. CMS recently published the PQRS Strategic Vision, which presents a long-term vision to optimize quality measurements and align physicians, professionals, and public reporting programs to support better decision-making across the healthcare system. "CMS will continue to move beyond 'check box' process measures. PQRS will be dominated by patient-centered outcome and longitudinal measures that reflect change to health status over time." The use of this measure would misdirect the VISION objective to measure outcomes, impinge on dealing with socio-demographic factors and women’s cardiovascular disease, and hamper CDC data needs for achieving Million Hearts. In summary, we do not support the use of this measure with the change to this measure as the new referenced guideline is controversial and not endorsed by all relevant specialty medicine professions, including the American Association of Clinical Endocrinologists. Removal of the LDL screening and control components of the measure without adding any means of evaluating hyperlipidemia treatment seems counterproductive and harmful to patients. While the ACC/ AHA guidelines do not identify a target LDL goal, they do state that once statin therapy is initiated, monitoring should occur using LDL levels to ensure optimal treatment selection and appropriate decrease in LDL levels. We think it is important to maintain a measure component to evaluate lipid treatment and monitoring in this patient population. B. Why ‘statin use’ alone is not sufficient to achieve optimal results. Matching the appropriate dose of the statin (and achieving the desired therapeutic response) for the individual patient’s level of ASCVD risk is the fundamental recommendation of the AHA/ACC 2013 guidelines, it is the matching of risk to dose/treatment that is responsible for the desired reduction in ASCVD events premise. The recommendation of the ACC/AHA guidelines and other national guidance (e.g. NLA, AACEE), is not to just prescribe any statin at any dose, as evidenced by the specificity of recommendations for the intensity of dosing by patient population and the grouping of drugs with dosing into the different intensity recommendations. Our concern is that this measure will give a passing mark to everyone who orders a statin for a patient and will not have the intended effect of providing patients with the intensity of therapy appropriate for their level of risk which is what is required to achieve maximum reduction in ASCVD risk. In addition, we have not seen the specifications and are concerned that the numerator will not include other lipid-lowering agents which may be required for appropriate, optimal management of many patients who are either statin intolerant or resistant. This may impact up 40-60% of the patients. For many, the combination of a statin with another drug (ezetimibe or niacin) is needed to achieve the desired reduction. (Karalis 2012. doi:10.1155/2012/861924). This is supported by the positive results of the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT). This trial evaluated the potential benefit for reduction in major cardiovascular (CV) events from the addition of ezetimibe versus placebo to statin therapy (Blazing, 2014: 205-212). IMPROVE-IT results were presented at the AHA Scientific Sessions 2014, including separate analyses of the intent-to-treat and on-treatment patient populations. Trial results met primary endpoint, showing ~ 2% reduction in CV events with Vytorin (ezetimibe/simvastatin) vs. simvastatin (HR=0.936, p=0.016; 6.4% relative risk reduction). IMPROVE-IT results are consistent with the established relationship between absolute reductions in LDL-C and reductions in major CV events (Baigent, 2010: 167-81). It is the first trial to show that adding a non-statin to a statin to further reduce LDL-C levels can help to reduce CV events. Because of the need for combination therapy to achieve therapeutic results and the time lag in incorporating new evidence and drugs in the guidelines, the addition of “statins and other lipid-lowering drugs” would allow the measure to be timely as new evidence and drugs become available. (Submitted by: SMT, Inc.)

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

The measure overlaps with other measures currently in MSSP (statin therapy, controlling high blood pressure and IVD-use of aspirin) and should not be included in the program. (Submitted by: Premier)
This measure is not NQF-endorsed (Submitted by: AdvaMed)

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

Although it does not look like a hospital measure currently, the New Corneal Injury Not Diagnose in the PACU/ Recovery, it would be difficult to capture this and track back to the anesthesiologist/surgical encounter once the patient is in the clinic setting. (Submitted by: Intermountain Healthcare)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Optometric Association (AOA) recommends that the numerator for MUC15-296 include a test that uses orange dye (fluorescein) and a blue light to detect damage to the cornea. The cornea is the clear outer surface of the eye, and without this dye and blue light, damage cannot be seen and will be missed. Viewing devices incorporating blue light, and the ophthalmic fluorescein strips necessary to accomplish this evaluation are inexpensive. Furthermore, this recommended screening that uses orange dye (fluorescein) and a blue light is of low risk to the individual being screened for corneal abrasion. Additionally, this is the only test that allows the provider to determine the location and likely cause of a cornea injury depending on the size, location, and shape of the staining. Left undiagnosed and untreated such corneal injuries run a high risk of infection and painful and often recurrent erosions and ulceration. (Submitted by: American Optometric Association)

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

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

The AMA strongly encourages NQF MAP to recommend these measures for inclusion in federal quality reporting programs, including the MIPS measure set. This is an important outcome measure that measures achievement of postoperative improved visual acuity, a desired surgical goal that improves patients’ daily activities of daily living and quality of life. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend these measures for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure that measures achievement of postoperative improved visual acuity, a desired surgical goal that improves patients’ daily activities of daily living and quality of life. In 2014, 47,530 corneal transplants were performed in the US. This measure evaluates the outcome of this final-stage option to restore sight and function in these patients with a dysfunctional cornea resulting in significant visual loss. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Optometric Association (AOA) recommends that the numerator of MUC15-370 include a test for visual acuity of 20/40 or better at least every 6-12 months after surgery and for a minimum of 5 years. Only through longitudinal measurement of acuity improvement, can we assess surgical risk to benefit and fully counsel the patient. (Submitted by: American Optometric Association)

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

The AMA encourages NQF MAP to recommend these measures for inclusion in federal quality reporting programs, including the MIPS measure set. This is an important outcome measure that measures the reduction in intraocular pressure, the only modifiable risk factor for glaucoma. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure that measures the reduction in intraocular pressure, the only modifiable risk factor for glaucoma. This measure has a significant impact on public health. 45 million people in the world have open-angle glaucoma (OAG), and glaucoma is the second leading cause of blindness, with approximately 8.4 million people blind from glaucoma. OAG affects an estimated 2.2 million people in the United States, and that number is likely to increase to 3.3 million in 2020 as the population ages. In 2011, 2.71 million persons in the United States had primary open-angle glaucoma (POAG), and the largest demographic group is non-Hispanic white women. This measure helps in addressing health disparities because minority populations have a higher prevalence rate for glaucoma. Overall, there appears to be a threefold higher prevalence of OAG in African Americans relative to non-Hispanic Whites in the United States. Recent evidence on Hispanics/Latinos suggests that they have high prevalence rates of OAG that are comparable to African Americans. Based on studies in the literature reviewing documentation of IOP achieved under care, the gap could be as great as 50% or more in the community of ophthalmologists and optometrists treating patients with primary open-angle glaucoma. Based on loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma. Another study of a single comprehensive insurance plan suggested that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are falling out of care and are being monitored at rates lower than expected from recommendations of published guidelines. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
Intraocular Pressure (IOP) is not a sole indicator of severity of glaucoma. To judge severity, additional components are necessary, including the following: gonioscopy (the use of a goniolens in conjunction with a slit lamp to gain a view the presence of any peripheral anterior synechiae (PAS) and the anatomical angle between the eye’s cornea and iris), serial visual field testing, serial tonometry, optical coherence tomography (noninvasive, noncontact, transpupillary imaging technology which can image cross-sectional retinal structures through a technique described by confocal scanning laser tomography), and corneal pachymetry (the process of measuring the thickness of the cornea) among other tests, depending on a person’s age and other risk factors. Therefore, the American Optometric Association (AOA) would support the measure with the following change to the denominator: Denominator: Patients aged between 40 and 85 years, with a minimum of 4 office visits during the prior 24 months, with a diagnosis of glaucoma and with documentation of the severity of their condition, based on ophthalmoscopy and or optical coherence tomography, gonioscopy, serial visual field testing and corneal pachymetry. (Submitted by: American Optometric Association)

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

The AMA encourages NQF MAP to recommend these measures for inclusion in federal quality reporting programs, including the MIPS measure set. This is an important outcome measure that measures reduction in intraocular pressure, the only modifiable risk factor for glaucoma. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure that measures reduction in intraocular pressure, the only modifiable risk factor for glaucoma. Given the public health importance, including the high prevalence of glaucoma, particularly among minority populations, and the benefits of achieving the outcome evaluated by the measure, we encourage MAP to recommend this measure for use. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: American Optometric Association)

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)

The AMA encourages NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure for acquired involutional ptosis that measures improved marginal reflex distance, a desired goal to improve patient clinical and functional outcomes. (Submitted by: American Medical Association)
ASPS is pleased to see meaningful and relevant measures for plastic surgeons in the MIPS program. Going forward, ASPS wishes to continue to see more relevant measures for specialties and surgical specialties. (Submitted by: American Society of Plastic Surgeons)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for acquired involutional ptosis that measures improved marginal reflex distance, a desired goal to improve patient clinical and functional outcomes. Studies in the United States on the prevalence of ptosis are lacking, but one study looking at individuals 50 years of age and older in England discovered that 11.5% had ptosis and that the prevalence increased with age. Patients with ptosis may have blurred vision, and may need to lift an eyelid with a finger, or tilt their head backwards in order to see. This measure evaluates the achievement of a desired outcome that would improve a patient’s ability to see. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Optometric Association (AOA) recommends that the numerator of MUC15-375 includes presence of corneal exposure keratitis due to poor lid closure. Patients must understand the benefits versus harms before choosing elective surgery and for cost/benefit ratios. This measure will allow us to quantify these factors. (Submitted by: American Optometric Assocation)

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

The AMA encourages NQF MAP to recommend inclusion in the MIPS measure set. This is an important outcome measure for acquired involutional entropian that measures normalized lid position, a desired goal to improve clinical and functional outcomes for the patient. (Submitted by: American Medical Association)
ASPS is pleased to see meaningful and relevant measures for plastic surgeons in the MIPS program. Going forward, ASPS wishes to continue to see more relevant measures for specialties and surgical specialties. (Submitted by: American Society of Plastic Surgeons)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for acquired involutional entropion that measures normalized lid position, a desired goal to improve clinical and functional outcomes for the patient. In a study of nearly 25,000 individuals over 60 years old, involutional entropion was found in 2.1% of patients. Prevalence increased with age: 0.9% for patient 60-69 years old, 2.1% for 70-79, and 7.6% for those over 80. Bilateral disease is three times more common than unilateral. Entropion is more common in women, with prevalence 2.4%, than men, prevalence 1.9%. Involutional entropion has a prevalence of 2.4% in whites and 0.8% in blacks. Patients with involutional entropion are often elderly and have significant comorbidities. The 4-year mortality for patients with involutional entropion is 30%. Patients with ptosis may have blurred vision, and may need to lift an eyelid with a finger, or tilt their head backwards in order to see. This measure evaluates the achievement of a desired outcome that would improve a patient’s ability to see. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Optometric Association would support this measure if it the numerator included reporting of post-operative presence of corneal exposure keratitis due to poor lid closure. Patients must understand the benefits versus harms before choosing elective surgery and for cost/benefit ratios. This measure will allow us to quantify these factors. (Submitted by: American Optometric Association )

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

We encourage NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure that measures maintenance of visual acuity, a desired treatment goal for exudative age-related macular degeneration to continue the level of the patient's daily activities of daily living and quality of life. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure that measures maintenance of visual acuity, a desired treatment goal for exudative age-related macular degeneration to continue the level of the patient's daily activities of daily living and quality of life. In addition, this measure is greatly important to public health. Approximately 1.75 million people age 40 years or older in the United States have neovascular AMD or geographic atrophy and 7.3 million have large drusen (=125 microns) in one or both eyes. AMD causes approximately 46 percent of cases of severe visual loss (visual acuity 20/200 or worse) in Americans older than 40 years old. AMD is among the top 25 disease conditions in cost for Medicare. AMD is a leading cause of blindness and visual impairment in the Medicare population. In the US, a total of 8 million individuals at least 55 years old have monocular or binocular intermediate AMD or monocular advanced AMD, and are at risk for developing advanced AMD. Of this high risk group, it is estimated that 1,315,000 individuals would develop advanced AMD within 5 years. AMD causes 46 percent of cases of severe visual loss (visual acuity 20/200 or worse) in Americans older than 40 years. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
Age related macular degeneration deprives our older population of not only sight, but independence and quality of life. Many of these patients have to limit or forgo driving, and many of the vocations of which they were accustomed. Measuring Visual Acuity in this population is critical to understand treatment modalities and their success or lack of for this disease. (Submitted by: American Optometric Association)

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

We encourage NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure for nonexudative age-related macular degeneration that measures maintenance of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for nonexudative age-related macular degeneration that measures maintenance of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. In addition, this measure is greatly important to public health. Approximately 1.75 million people age 40 years or older in the United States have neovascular AMD or geographic atrophy and 7.3 million have large drusen (=125 microns) in one or both eyes. AMD causes approximately 46 percent of cases of severe visual loss (visual acuity 20/200 or worse) in Americans older than 40 years old. AMD is among the top 25 disease conditions in cost for Medicare. AMD is a leading cause of blindness and visual impairment in the Medicare population. In the US, a total of 8 million individuals at least 55 years old have monocular or binocular intermediate AMD or monocular advanced AMD, and are at risk for developing advanced AMD. Of this high risk group, it is estimated that 1,315,000 individuals would develop advanced AMD within 5 years. AMD causes 46 percent of cases of severe visual loss (visual acuity 20/200 or worse) in Americans older than 40 years. Three randomized clinical trials (ANCHOR , MARINA , and PIER ) demonstrated that with effective anti-VEGF treatment at the appropriate stage of disease, 90-96% of patients lost less than 15 letters of visual acuity, and 33 – 40% of patients gained more than 15 letters of visual acuity. Based on this scientific evidence, timely and effective treatment can be provided to patients who are staged accurately, thus avoiding the blindness and visual impairment associated with the natural progression of disease. No data exists on the identification and documentation of the severity of macular degeneration and presence or absence of macular thickening but parallel data for key structural assessments for glaucoma and cataract and diabetic retinopathy suggest that significant gaps are likely. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
Age related macular degeneration deprives our older population of not only sight, but independence and quality of life. Many of these patients have to limit or forgo driving, and many of the vocations of which they were accustomed. Measuring Visual Acuity in this population is critical to understand treatment modalities and their success or lack of for this disease. (Submitted by: American Optometric Association)

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

We encourage NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure for diabetic macular edema that measures maintenance of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. (Submitted by: American Medical Association)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for diabetic macular edema that measures maintenance of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. The public health impact of this measure is significant and will increase with the aging of the population. In 2005–2008, 4.2 million people with diabetes aged 40 years or older had diabetic retinopathy. The numbers of affected patients will rise dramatically, with the number tripling in 2050 to 16.0 million with diabetic retinopathy, and 3.4 million with vision threatening diabetic retinopathy. The elderly population will have the greatest increases in the numbers with diabetes-related eye disease. The natural progression of diabetic retinopathy is to advance with age and severity of diabetes mellitus resulting in visual impairment and blindness. Diabetic macular edema, a manifestation of diabetic retinopathy, is the most frequent cause of blindness in young and mid-aged adults. Several level 1 randomized controlled trials studies demonstrate the ability of timely treatment to reduce the rate and severity of vision loss from diabetes (–DRS and ETDRS). Treatment of diabetic macular edema, a common cause of visual impairment, has been significantly enhanced with the introduction of anti- VEGF. The Diabetic Retinopathy Clinical Research Network study found that the mean change in visual acuity was significantly greater in patients receiving ranibizumab plus prompt/deferred laser surgery (+9 letters) compared to treatments without anti-VEGF agents. (Submitted by: American Academy of Ophthalmology)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: American Optometric Association )

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

We encourage NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure for acute anterior uveitis that measures improvement of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. (Submitted by: American Medical Association)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for acute anterior uveitis that measures improvement of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. This measure would address a gap in care; despite relatively low incidence rates, uveitis is the third leading cause of preventable blindness in developed countries, and sight-threatening complications of uveitis include glaucoma, damage to the retina and macular edema. Available data strongly indicate that active inflammation is correlated with visual loss and that higher levels of inflammation are associated with a greater risk of visual loss. Furthermore, active inflammation is a risk factor for the occurrence of structural complications, which often are the cause of visual loss. The preservation/improvement in visual acuity is the ultimate goal. (Submitted by: American Academy of Ophthalmology)
While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: American Optometric Association)

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

The AMA encourages NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure for acute anterior uveitis that measures reduction of inflammation, a desired treatment goal for improved clinical and functional outcome. (Submitted by: American Medical Association)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for acute anterior uveitis that measures reduction of inflammation, a desired treatment goal for improved clinical and functional outcome. This measure would address a gap in care; despite relatively low incidence rates, uveitis is the third leading cause of preventable blindness in developed countries, and sight-threatening complications of uveitis include glaucoma, damage to the retina and macular edema. Available data strongly indicate that active inflammation is correlated with visual loss and that higher levels of inflammation are associated with a greater risk of visual loss. Furthermore, active inflammation is a risk factor for the occurrence of structural complications, which often are the cause of visual loss. Therefore, a primary goal of treatment (when treatment is needed) is suppression of inflammation to grade 0 cells (inactive disease). The use of the Standardization of Uveitis Nomenclature (SUN) grading system, which is widely accepted and has excellent interobserver agreement, is encouraged for grading anterior chamber inflammation. For acute anterior uveitis, treatment then is tapered and discontinued and treatment of the acute attacks is appropriate. (Submitted by: American Academy of Ophthalmology )
The American Optometric Association recommends that MUC15-396 should include grade 0 flare in addition to Grade 0 cells. These together describe the degree of anterior uveitis. (Submitted by: American Optometric Association )

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

The AMA encourages NQF MAP to recommend these measures for inclusion in the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for chronic anterior uveitis that measures improvement of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. (Submitted by: American Medical Association)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure for chronic anterior uveitis that measures improvement of visual acuity, a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life. This measure would address a gap in care; despite relatively low incidence rates, uveitis is the third leading cause of preventable blindness in developed countries, and sight-threatening complications of uveitis include glaucoma, damage to the retina and macular edema. Available data strongly indicate that active inflammation is correlated with visual loss and that higher levels of inflammation are associated with a greater risk of visual loss. Furthermore, active inflammation is a risk factor for the occurrence of structural complications, which often are the cause of visual loss. The preservation/improvement in visual acuity is the ultimate goal. (Submitted by: American Academy of Ophthalmology)
The American Optometric Association recommends that MUC15-397 should include grade 0 flare in addition to Grade 0 cells. These together describe the degree of anterior uveitis. (Submitted by: American Optometric Association)

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

The AMA encourages NQF MAP to recommend these measures for inclusion in the MIPS measure set. This is an important outcome measure chronic anterior uveitis that measures reduction of inflammation, a desired treatment goal for improved clinical and functional outcome. (Submitted by: American Medical Association)
This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American Academy of Ophthalmology strongly encourages NQF MAP to recommend this measure for inclusion in federal quality reporting programs, including the MIPS measure set. This measure has been accepted by CMS as a qualified clinical data registry measure available and currently used for PQRS reporting through the Academy’s QCDR, IRIS Registry. This is an important outcome measure chronic anterior uveitis that measures reduction of inflammation, a desired treatment goal for improved clinical and functional outcome. This measure would address a gap in care; despite relatively low incidence rates, uveitis is the third leading cause of preventable blindness in developed countries, and sight-threatening complications of uveitis include glaucoma, damage to the retina and macular edema. Available data strongly indicate that active inflammation is correlated with visual loss and that higher levels of inflammation are associated with a greater risk of visual loss. Furthermore, active inflammation is a risk factor for the occurrence of structural complications, which often are the cause of visual loss. Therefore, a primary goal of treatment (when treatment is needed) is suppression of inflammation to grade 0 cells (inactive disease). The use of the Standardization of Uveitis Nomenclature (SUN) grading system, which is widely accepted and has excellent interobserver agreement, is encouraged for grading anterior chamber inflammation. For chronic anterior uveitis, treatment is tapered to topical corticosteroid equivalents of prednisolone acetate 1% 3 times daily or less while maintaining grade 0 anterior chamber cells. The use of systemic medications may be necessary to achieve this goal and the choice is disease and ‘host” specific. Long-term goals include the prevention of structural complications, including posterior synechiae, ocular hypertension/glaucoma, and cataracts. (Submitted by: American Academy of Ophthalmology)
The American Optometric Association recommends that MUC15-399 include grade 0 flare in addition to Grade 0 cells. These together describe the degree of anterior uveitis.. (Submitted by: American Optometric Association)

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

This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

The measure is appropriate and it will stimulate earlier discussion and referral to hospice services for persons with advanced cancer, thereby improving their quality of care and helping lighten the burden for their caregivers. However, the problem of very late referral to hospice care is not limited to oncology alone. Rather, this pattern is seen with a broad array of chronic illness, including COPD, liver disease, etc. Thus the application of this proposed measure should be broadened in scope to encompass essentially all chronic advanced illness; anything less implies that the problem is far more limited in is scope than reality reveals. (Submitted by: The Coalition to Transform Advanced Care)
This MIPS measure is very good. Hospices have reported seeing an uptick in late oncology referrals as payment policies have changed. We recommend that it be considered for broader utilization by other provider types, for causes of death other than cancer, and the length of stay be extended to a longer timeframe. Earlier referral to hospice means end-of-life pain and symptoms can be aggressively addressed and crises, such as hospitalizations, can be avoided. (Submitted by: National Association for Home Care & Hospice (NAHC))
This MIPS measure is very good. Hospices have reported seeing an uptick in late oncology referrals as payment policies have changed. We recommend that it be considered for broader utilization by other provider types, for causes of death other than cancer, and the length of stay be extended to a longer timeframe (at least 10 days). Earlier referral to hospice means end-of-life pain and symptoms can be aggressively addressed and crises, such as hospitalizations, can be avoided. (Submitted by: The Home Care & Hospice Association of New Jersey)
This MIPS measure is very good. Hospices have reported seeing an uptick in late oncology referrals as payment policies have changed. We recommend that it be considered for broader utilization by other provider types, for causes of death other than cancer, and the length of stay be extended to a longer timeframe. Earlier referral to hospice means end-of-life pain and symptoms can be aggressively addressed and crises, such as hospitalizations, can be avoided. (Submitted by: Ohio Council for Home Care & Hospice)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

This measure is currently being field tested, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-434)

American Urogynecologic Society believes this is a valuable measure because the use of bulking agents should be utilized in appropriate patients with Intrinsic Sphincter Deficiency. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This is not an outcome measure. (Submitted by: American College of Obstetricians and Gynecologists)

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

American Urogynecologic Society believes implementation of this measure will determine if best care practices are being followed when treating women with disorder. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American College of Obstetricians and Gynecologists supports this measure. It should reduce complications and costs without sacrificing positive outcomes for patients. (Submitted by: American College of Obstetricians and Gynecologists)

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

American Urogynecologic Society believes this is a valuable measure because vaginal hysterectomy has been shown to be the safest method of hysterectomy. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
The American College of Obstetricians and Gynecologists supports this measure. It should drive use of minimally invasive surgical procedures and avoids overuse of robotic surgery. (Submitted by: American College of Obstetricians and Gynecologists)

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

American Urogynecologic Society believes this is a valuable measure because it will help ensure that patients who do have a uterine malignancy are diagnosed prior to colpocleisis. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

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

American Urogynecologic Society believes it is important to ensure that patients are offered the opportunity to pursue conservative management prior to surgery, as assessed in this measure. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

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

While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: American Urological Association)
American Urogynecologic Society believes current guidelines issued by the American Urologic Association that state that behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) should be first line therapy, as assessed in this measure. (Submitted by: American Urogynecologic Society)
This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

We strongly support inclusion of this measure for consideration in MIPS and other CMS quality programs. The clinical and economic value of minimally invasive surgery for appropriate patients is very well documented in peer reviewed literature as noted in Appendix B, Measure Rationales. Quality measures which encourage the adoption of MIS for appropriate patients represent an opportunity to improve outcomes, reduce costs, and reduce variability of care. We encourage review of “Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review” BMJ 2014;349:g4198 doi: 10.1136/bmj.g4198 (Published 8 July 2014) and “Hospital Cost Implications of Increased Use of Minimally Invasive Surgery” Published Online: March 25, 2015. doi:10.1001/jamasurg.2014.4052 as this measure is considered. (Submitted by: Medtronic)
Quality measures which encourage the adoption of minimally invasive surgery (MIS) for appropriate patients represents an opportunity to improve outcomes and reduce costs. However, this measure has never been submitted to NQF for evaluation/endorsement. We support inclusion of this measure – only pending future NQF-endorsement -- for consideration in MIPS. (Submitted by: AdvaMed)
The American College of Obstetricians and Gynecologists supports this measure. It should drive use of minimally invasive surgical procedures . (Submitted by: American College of Obstetricians and Gynecologists)
We support inclusion of this measure for consideration in MIPS. While not NQF-endorsed, as noted in Appendix B, Measure Rationales, there is strong, peer reviewed, published evidence of the clinical and economic benefits of the minimally invasive approach for hysterectomy procedures. Quality measures which encourage the adoption of MIS for appropriate patients represents an opportunity to improve outcomes and reduce costs. We further encourage the consideration of adopting as quality measures the proportion of MIS for other procedures where there exists strong evidence of MIS clinical benefits for consideration under MIPS and other CMS quality programs. (Submitted by: Medtronic)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

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)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

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)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. (Submitted by: American College of Obstetricians and Gynecologists)

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)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)
This measure represents good practice in gynecology. It supports referral to appropriate providers to ensure optimal care for patients with curable cervical cancer. (Submitted by: American College of Obstetricians and Gynecologists)

This measure is currently in the early stage of development, has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

These measures are intended to be implemented and reported at the metropolitan area or county level (per 100,000) and have been endorsed as such by the National Quality Forum (NQF) with the exception of PQI 8 (Heart Failure), which is at the health plan/integrated delivery system level. Applying measures that are intended to assess overall admission rates at a population level to individual physicians in the MIPS program seems imprudent; particularly, as there may be significant concerns with small sample sizes and applicability to the various physician specialties. In addition, PQI 91 and 92 have not been endorsed by the NQF and therefore the composite constructs, attribution, weighting and other issues have not been vetted by experts outside of AHRQ. We recommend that MAP does not support these measures until additional information on how these measures would be implemented in MIPS are provided. While the MUC listing lists MIPS as the intended program, it seems that this measure may be used as a claims-based quality measure that all MIPS participants would be evaluated against. Such a measure would be flawed, as it would hold EPs accountable for inpatient admissions related to conditions they do not treat. This would also unfairly penalize EPs that treat high risk patients with multiple chronic conditions, especially given that there appears to be no risk adjustment outlined. (Submitted by: American Medical Association)
The American Academy of Ophthalmology encourages MAP to oppose the inclusion of this measure in federal programs. We lack clarity around the intended use for this measure. While the MUC listing references MIPS as the intended program, it seems that this measure may be used as a claims-based quality measure that all MIPS participants would be evaluated against. Such a measure would be flawed, as it would hold EPs accountable for inpatient admissions related to conditions they do not treat. This would also unfairly penalize EPs that treat high risk patients with multiple chronic conditions, especially given that there appears to be no risk adjustment outlined. (Submitted by: American Academy of Ophthalmology)

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

If the PQI composites are added to MSSP, the existing unplanned admission measures (diabetes, heart failure, multiple chronic conditions) should be removed. The PQI composites are preferrable since they are used in the value-modifier and all physicians who participate in an MSSP ACO are also subject to the value modifier. Having one set of measures related to admissions for ambulatory sensitive conditions will reduce measurement burden for ACO participants. (Submitted by: Premier)
All of the measures that comprise the composite are intended to be measured at the metropolitan area of county level, per 100,000. Depending on the composition and size of the ACO, this measure may not be feasible to implement in the MSSP and physician practices would most certainly never meet the minimum threshold required for the measure. If you are an ACO and you are accountable for costs, then using measures of admissions and readmissions is inappropriate. The ACO has a natural incentive to reduce avoidable admissions and readmissions. In some cases, the ACO may decide the patient should be hospitalized or readmitted because that's more efficient than forcing them to pursue office visits or to provide home care, but the ACO doesn't have the flexibility to do that because of a measure that declares hospitalizations and readmissions to be bad in all cases. In addition, information on how the measure performs at the ACO level has not been provided for existing measures in the Medicare Shared Saving Program or Value-based Payment Modifier nor have they been submitted to NQF for review. We recommend that the MAP does not support these measures The AMA would also like to highlight the following additional areas of concern with CMS’ modified use of the measure within the MSSP. Only six of the nine indicators from PQI 92 are included in the Chronic Ambulatory Sensitive Condition Composite. Only PQI 8 (Heart failure) is intended to be used at the health plan or integrated delivery system level. The rest of the measures are intended for us at the county or city level of analysis. In addition, the full composite is not endorsed by NQF so information on how these measures perform at the ACO level are unknown. Currently, within MSSP, only two AHRQ PQI measures are included in the program, which is PQI 5 (COPD and Asthma) and PQI 8 (heart failure). Currently, CMS modified the measures as follows: For the purposes of the CMS ACO initiatives, the following modifications were made to the original AHRQ Prevention Quality Indicator (PQI) version 4.4 technical specifications: 1) denominator changed from general population in a geographic area to beneficiaries assigned or aligned to a Medicare ACO including part-year beneficiaries; 2) denominator changed from patients of any disease status to beneficiaries with a diagnosis of COPD or Asthma; and 3) added a denominator exclusion for beneficiaries with ESRD. To verify that these modifications were valid, the following analyses were completed: 1) dry run testing, 2) validity testing, 3) reliability testing, 4) variability testing and 5) exclusion testing. However, results from the analyses could not be found. The AMA did look at testing related to PQI 5 and 8 that was submitted for NQF maintenance, which is part of PQI 92. The testing form for PQI 5 is currently blank. It appears for PQI 8, no new testing was submitted; rather the testing from the previous endorsement maintenance review in 2010 is provided. This is consistent with the update NQF maintenance process where developers do not need to provide updated info if the measure has not changed. However, there still are a few issues with the testing provided. 1st, the info is not sufficiently detailed to indicate whether the testing was performed at an ACO level or whether it was completed at the county/city level. Second, the c-statistic for the risk-adjustment is not reported. Also the performance scores provided in the submissions are reported at the regional level. Thus, no info on how the measure performs at the health plan, integrated delivery system or ACO are provided. (Submitted by: American Medical Association)
This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

These measures are intended to be implemented and reported at the metropolitan area or county level (per 100,000) and have been endorsed as such by the National Quality Forum (NQF) with the exception of PQI 8 (Heart Failure), which is at the health plan/integrated delivery system level. Applying measures that are intended to assess overall admission rates at a population level to individual physicians in the MIPS program seems imprudent; particularly, as there may be significant concerns with small sample sizes and applicability to the various physician specialties. In addition, PQI 91 and 92 have not been endorsed by the NQF and therefore the composite constructs, attribution, weighting and other issues have not been vetted by experts outside of AHRQ. We recommend that MAP does not support these measures until additional information on how these measures would be implemented in MIPS are provided and the measure with this information submitted to NQF for review. While the MUC listing lists MIPS as the intended program, it seems that this measure may be used as a claims-based quality measure that all MIPS participants would be evaluated against. Such a measure would be flawed, as it would hold EPs accountable for inpatient admissions related to conditions they do not treat. This would also unfairly penalize EPs that treat high risk patients with multiple chronic conditions, especially given that there appears to be no risk adjustment outlined. (Submitted by: American Medical Association)
These measures are intended to be implemented and reported at the metropolitan area or county level (per 100,000) and have been endorsed as such by the National Quality Forum (NQF) with the exception of PQI 8 (Heart Failure), which is at the health plan/integrated delivery system level. Applying measures that are intended to assess overall admission rates at a population level to individual physicians in the MIPS program seems imprudent; particularly, as there may be significant concerns with small sample sizes and applicability to the various physician specialties. In addition, PQI 91 and 92 have not been endorsed by the NQF and therefore the composite constructs, attribution, weighting and other issues have not been vetted by experts outside of AHRQ. We recommend that MAP does not support these measures until additional information on how these measures would be implemented in MIPS are provided. While the MUC listing lists MIPS as the intended program, it seems that this measure may be used as a claims-based quality measure that all MIPS participants would be evaluated against. Such a measure would be flawed, as it would hold EPs accountable for inpatient admissions related to conditions they do not treat. This would also unfairly penalize EPs that treat high risk patients with multiple chronic conditions, especially given that there appears to be no risk adjustment outlined. (Submitted by: American Medical Association)
The American Academy of Ophthalmology encourages MAP to oppose the inclusion of this measure in federal programs. We lack clarity around the intended use for this measure. While the MUC listing references MIPS as the intended program, it seems that this measure may be used as a claims-based quality measure that all MIPS participants would be evaluated against. Such a measure would be flawed, as it would hold EPs accountable for inpatient admissions related to conditions they do not treat. This would also unfairly penalize EPs that treat high risk patients with multiple chronic conditions, especially given that there appears to be no risk adjustment outlined. (Submitted by: American Academy of Ophthalmology)

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

If the PQI composites are added to MSSP, the existing unplanned admission measures (diabetes, heart failure, multiple chronic conditions) should be removed. The PQI composites are preferrable since they are used in the value-modifier and all physicians who participate in an MSSP ACO are also subject to the value modifier. Having one set of measures related to admissions for ambulatory sensitive conditions will reduce measurement burden for ACO participants. (Submitted by: Premier)
All of the measures that comprise the composite are intended to be measured at the metropolitan area of county level, per 100,000. Depending on the composition and size of the ACO, this measure may not be feasible to implement in the MSSP and physician practices would most certainly never meet the minimum threshold required for the measure. If you are an ACO and you are accountable for costs, then using measures of admissions and readmissions is inappropriate. The ACO has a natural incentive to reduce avoidable admissions and readmissions. In some cases, the ACO may decide the patient should be hospitalized or readmitted because that's more efficient than forcing them to pursue office visits or to provide home care, but the ACO doesn't have the flexibility to do that because of a measure that declares hospitalizations and readmissions to be bad in all cases. In addition, information on how the measure performs at the ACO level has not been provided for existing measures in the Medicare Shared Saving Program or Value-based Payment Modifier nor have they been submitted to NQF for review. We recommend that the MAP does not support these measures The AMA would also like to highlight the following additional areas of concern with CMS’ modified use of the measure within the MSSP. All of the indicators included in PQI 91 (Acute) are endorsed by NQF at the county or city level of analysis. Two of the indicators are not endorsed by NQF. Of the seven that are endorsed, all but one is intended to be reported at the county or city level of analysis. In addition, the full composite is not endorsed by NQF so information on how these measures perform at an ACO level is unknown. Currently, within MSSP, only two AHRQ PQI measures are included in the program, which is PQI 5 (COPD and Asthma) and PQI 8 (heart failure). Currently, CMS modified the measures as follows: For the purposes of the CMS ACO initiatives, the following modifications were made to the original AHRQ Prevention Quality Indicator (PQI) version 4.4 technical specifications: 1) denominator changed from general population in a geographic area to beneficiaries assigned or aligned to a Medicare ACO including part-year beneficiaries; 2) denominator changed from patients of any disease status to beneficiaries with a diagnosis of COPD or Asthma; and 3) added a denominator exclusion for beneficiaries with ESRD. To verify that these modifications were valid, the following analyses were completed: 1) dry run testing, 2) validity testing, 3) reliability testing, 4) variability testing and 5) exclusion testing. However, results from the analyses could not be found. The AMA did look at testing related to PQI 5 and 8 that was submitted for NQF maintenance, which is part of PQI 92. The testing form for PQI 5 is currently blank. It appears for PQI 8, no new testing was submitted; rather the testing from the previous endorsement maintenance review in 2010 is provided. This is consistent with the update NQF maintenance process where developers do not need to provide updated info if the measure has not changed. However, there still are a few issues with the testing provided. 1st, the info is not sufficiently detailed to indicate whether the testing was performed at an ACO level or whether it was completed at the county/city level. Second, the c-statistic for the risk-adjustment is not reported. Also the performance scores provided in the submissions are reported at the regional level. Thus, no info on how the measure performs at the health plan, integrated delivery system or ACO are provided. (Submitted by: American Medical Association)
This measure has never been submitted to NQF and thus is not NQF-endorsed (Submitted by: AdvaMed)

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

The measure is appropriate and it will stimulate the targeted providers (those influenced by MIPS and MSSP) to expand and improve their advance care planning efforts. However, only some 400 organizations are part of the MSSP; broader application of this measure to essentially all hospitals would address a great national need that extends far beyond MSSP participant organizations. (Submitted by: The Coalition to Transform Advanced Illness)
Adds value to the program and addresses an important topic. Additionally, with payment for the CPT codes for advance care planning going into effect in 2016 this measure may become less burdensome with decreased need for medical record review as CPT code use increases. (Submitted by: Premier)
This measure for MSSP is a good starting point to promoting advance care planning, a necessary component to quality care. We recommend that this measure be added to the quality programs of other provider types and, eventually, be expanded to include measures assessing provider compliance with patient’s advance directive. Consideration should also be given in the future to including in the measure assessment of whether providers inform patients of the availability of advance care planning discussions, and provide referral in cases where the patient indicates an interest, if not directly having the discussion. This would be an especially appropriate measure for all physicians considering the fact that two new physician billing codes for advance care planning were added to the Physician Fee Schedule in 2016. (Submitted by: National Association for Home Care & Hospice (NAHC))
This measure for MSSP is a good starting point to promoting advance care planning, a necessary component to quality care. We recommend that this measure be added to the quality programs of other provider types and, eventually, be expanded to include measures assessing provider compliance with patient’s advance directive. (Submitted by: The Home Care & Hospice Association of New Jersey)
This measure for MSSP is a good starting point to promoting advance care planning, a necessary component to quality care. We recommend that this measure be added to the quality programs of other provider types and, eventually, be expanded to include measures assessing provider compliance with patient’s advance directive. (Submitted by: Ohio Council for Home Care & Hospice)

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

If added to MSSP this measure should replace the existing falls risk measure. This measure is preferrable as it goes beyond screening and requires a plan of care for beneficiaries at risk for falls. (Submitted by: Premier)
Falls are the leading cause of injury-related morbidity and mortality among older adults. Falls result in physical injury, including high rates of orthopedic and ocular injury, directly cause costly disability, and often increase hospital readmissions. In addition, important psychological consequences occur as a result of a fall, including depression, anxiety, activity restriction, and fear of falling. There is a plethora of evidence indicating that impaired vision is highly associated with and is an important risk factor of falls. Importantly, reduced visual acuity, as currently screened for, is not adequate to establish a falls risk associated with vision problems. A comprehensive eye exam is needed to fully assess known contributing factors to falls, including but not limited to, reduced contrast sensitivity, poor stereopsis and visual field loss (e.g. especially in the lower visual field) cataract, ptosis, and color vision deficiencies. Comprehensive eye examination can also identify other changes in the eye that can hinder daily function. As an example, a measured increase in sensitivity to glare and sunlight known to decrease binocularity and can be measured and subsequently compensated through optical correction. (Submitted by: America Optometric Association)

The Core Measure Collaborative, a multi-stakeholder group consisting of providers, health plans, consumers, and employers, have consensus on the most important measures for depression for primary care. They are NQF 0710 Depression Remission at 12 Months and NQF 1885 Depression Response at Twelve Months- Progress Towards Remission. The composite that’s currently under consideration does not include NQF 1885 Depression Response at Twelve Months- Progress Towards Remission. Because of the work of the Core Measure Collaborative, the AAFP strongly supports this measure not be considered as a composite, but rather the measures be evaluated individually. (Submitted by: American Academy of Family Physicians )
NRHI strongly supports the incorporation of proposed measure 928 (Paired measure - Depression Utilization of the PHQ-9 tool and Depression Remission at 6 months) The Center for Healthcare Transparency (CHT), a nonprofit initiative with the goal of making credible information on provider cost, quality and patient experience performance available to 50% of the US by 2020, has included this measure as one of only 15 high value measures on its Measure Dashboard. Over the next five years, we expect that each of the measures on this dashboard will be produced in a standard and consistent way by the 35+ multi-stakeholder regional entities that are expected to make up CHT’s national network of regional data intermediaries. Alignment on this measure would allow providers, payers and purchaser to use this measure for multiple quality improvement and value based payment purposes. This measure was identified as a strong candidate for the CHT measure dashboard through a careful process that began with CHT’s User Council members identifying measures they were ready to use to either deliver or pay for care differently. This measure was then vetted for inclusion in the dashboard by both CHT’s technical advisory council of national experts and the 13 member CHT “design team” of regional entities that have extensive experience implementing measures using aggregated data. (Submitted by: Network for Regional Healthcare Improvement)

Appendix D: Instructions and Help

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

Navigating the Discussion Guide

How do I get back to the section I was just looking at?
The easiest way is to use the back button on your browser. Other options are using your backspace button (which works for many browsers on laptops), or using the permanent links at the upper right hand corner of the discussion guide. But the back button is the best choice in most situations.
Can I print the discussion guide out?
You can, but we don't recommend it. Besides using a lot of paper (probably a couple hundred pages at least), you'll lose all the links that allow you to move around the document. For instance, if you're scrolling through the agenda and want to see more information about a particular measure, the electronic format will allow you to click a link, read more, and then bo back. If you're on paper, there will be a lot of flipping through paper.
If I can't print this out, how can I read it on the plane?
We will send you a pdf/Adobe Acrobat file a few days before the meeting, which will hopefully be useful when you're reviewing the discussion guide as you travel to Washington, DC.
How do I know that I'm looking at the most recent version?
At the top left corner of the discussion guide is a version number. At the beginning of the in person meetings, the NQF staff will ask everyone to load the most recent discussion guide version and will check that everyone has the same version loaded.
What electronic devices can I use to view the discussion guide?
We tried to make this as universal as possible, so it should work on your laptop (PC, Mac, Linux), your tablet (iPad, Android), or your phone (iPhone, Android). It should also work on many types of browsers (IE, Firefox, Chrome, Safari, Opera, Dolphin,....). Please let us know if you have any problems, and we'll troubleshoot with you (and improve the discussion guide for the next go around).
Why do I see weird characters in some places?
Because we're joining data from many different sources, we do find some technical challenges. This generally shows up as strange characters--extra question marks, accented characters, or otherwise unusual items. We've been able to fix many of these problems, but not all. We ask that you bear with us as we improve this over time!

Content

What is included in the discussion guide?
There are four sections within this document:
- Agenda, with summaries of each measure under consideration
- Full information about each measure, including its specifications, preliminary analysis of how this measure can advance the program's goals, and the rationale by HHS for being included in the list
- Summaries for each federal health program being considered
- Public comments that have been received to date (Note that the discussion guide may be released before the public comment period is finished, in which case there will just be a placeholder for where comments will go)
How are the meeting discussions organized?
The meeting sessions are organized around consent calendars, which are groups of measures being considered for a particular program or groups of measures for a particular condition or topic area. For each measure being discussed, this document will show you the description, the public comments (if any), the summary of the preliminary analysis, and the result of the preliminary analysis algorithm.

Appendix E: Instructions for Joining the Meeting Remotely

Remote Participation Instructions:

Streaming Audio Online

Direct your web browser to: http://nqf.commpartners.com/.
Under “Enter a Meeting” type in the meeting number for Day 1: 101837 or for Day 2: 377963
In the “Display Name” field, type in your first and last names and click “Enter Meeting.”

Teleconference

Dial 1 (888) 802-7237 for workgroup members or 1 (877) 303-9138 for public participants ; use conference ID code for Day 1: 72951586 or Day 2: 72953205 to access the audio platform.

Agenda | Measures | Programs | Comments

NQF

Measure Applications PartnershipClinician Workgroup Discussion Guide

Agenda

Agenda Synopsis

Full Agenda

Appendix A: Measure Information

Measure Index

Merit-Based Incentive Payment System (MIPS)

Medicare Shared Savings Program

Physician Compare

Full Measure Information

Appendix B: Program Summaries

Program Index

Full Program Summaries

Appendix C: Public Comments

Index of Measures (by Program)

General Comments

Merit-Based Incentive Payment System (MIPS)

Medicare Shared Savings Program

Physician Compare

Full Comments (Listed by Measure)

Appendix D: Instructions and Help

Navigating the Discussion Guide

Content

Appendix E: Instructions for Joining the Meeting Remotely

Remote Participation Instructions:

Measure Applications Partnership
Clinician Workgroup Discussion Guide