NQF

Agenda Synopsis

Full Agenda

Measure Index

• Ambulatory surgery patients with appropriate method of hair removal (Public comments received:1; MUC ID: E0515)
  
  

• Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization (Public comments received:2; MUC ID: X3727)
  
  
• Timely Evaluation of High-Risk Individuals in the Emergency Department (Public comments received: 0; MUC ID: X1234)
  
  

• IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Public comments received:8; MUC ID: S2633)
  
  

• Compliance with Ventilator Process Elements during LTCH stay (Public comments received:1; MUC ID: X3705)
  
  

• External Beam Radiotherapy for Bone Metastases (Public comments received: 0; MUC ID: E1822)
  
  

• Adult Kidney Disease: Referral to Hospice (Public comments received: 0; MUC ID: X3732)
  
  
• Evaluation or Interview for Risk of Opioid Misuse (Public comments received: 0; MUC ID: X3774)
  
  
• In-hospital mortality following elective open repair of AAAs (Public comments received: 0; MUC ID: E1523)
  
  

• Adult Kidney Disease: Referral to Hospice (Public comments received:1; MUC ID: X3732)
  
  
• Evaluation or Interview for Risk of Opioid Misuse (Public comments received:2; MUC ID: X3774)
  
  
• In-hospital mortality following elective open repair of AAAs (Public comments received: 0; MUC ID: E1523)
  
  

• Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (Public comments received:1; MUC ID: S2510)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable): 0515
  
  
• Description: Percentage of ASC admissions with appropriate surgical site hair removal.
  
  
• Numerator: ASC admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream from all other surgical sites
  
  
• Denominator: All ASC admissions with surgical site hair removal
  
  
• Exclusions: ASC admissions who perform their own hair removal
  
  
• HHS NQS Priority: Effective Prevention and Treatment
  
  
• HHS Data Source: Paper Medical Record
  
  
• Measure Type: Process
  
  
• Steward: ASC Quality Collaboration
  
  
• Endorsement Status: Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Do not support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure is not anticipated to have an impact on the program measure set. This measure is topped out with limited performance variation among providers. The measure has been removed from IQR and is not in, nor planned to be, in another program.
  • Impact on quality of care for patients:This measure is not anticipated to have an impact on the quality of care. Performance on this measure is topped out. Rates collected for 192 ASCs across the US demonstrated a mean rate of 96% and a median rate of 100%
  
  
  
• Does the measure address a program goal or objective? No. While appropriate method of hair removal does reduce the likelihood of infections, performance on this measure is topped out. Rates collected for 192 ASCs across the US demonstrated a mean rate of 96% and a median rate of 100%.
  
  
• Is this a high-value measure? No.. There is no performance gap or opportunity for improvement.
  
  
• Does this measure fill a gap in the program measure set? No. Although infection rates have been identified as a gap area for the ASCQR program the lack of performance variation on this measure would prevent it from providing meaningful results.
  
  
• Measure development status: Fully developed
  
  
• Is the measure currently in use? Yes. This measure is used by the ASC Quality Collaboration.
  
  
• Does a review of its performance history raise any concerns? Yes. Performance on this measure is topped out.
  
  
• Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. Measures of proper hair removal have been removed from IQR. Adding this measure would not drive performance and would increase measurement burden.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
  
  

Rationale for measure provided by HHS
The literature regarding preoperative hair removal has been systematically reviewed twice, once by Kjonniksen et al in 2002 and again by Tanner et al in 2007. Three randomized controlled trials (Alexander et al 1983, Balthazar et al 1983, Ko et al 1992) compared the rates of infection at the surgical site when hair removal at the site was performed with clippers or with razors. A statistically significant difference in infection rates in the pooled results (Tanner et al 2007) was seen, with 2.8% of the patients who were shaved developing a surgical site infection compared with 1.4% rate of surgical site infection in the patients who were clipped. Additional randomized controlled trials (Court-Brown 1981, Powis et al 1976, Seropian 1971, Thur de Koos 1983) have demonstrated that patients were more likely to develop a surgical site infection when shaved as compared to having hair removal with a depilatory. Observational studies have suggested that no hair removal is less likely to result in surgical site infection, but this has not been confirmed in randomized controlled trials. The HICPAC/CDC Guideline for Prevention of Surgical Site Infection (Mangram at al 1999), the Association of Operating Room Nurses Recommended Practices for Preoperative Patient Skin Antisepsis (AORN 2002) and the SHEA/IDSA Strategies to Prevent Surgical Site Infections in Acute Care Hospitals (Anderson et al 2008) are consistent with the intent of this measure. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound infections. Arch Surg. 1983 Mar;118(3):347-52. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61. Association of Operating Room Nurses. Recommended practices for skin preparation of patients. AORN J. 2002 Jan;75(1):184-7. Balthazar ER, Colt JD, Nichols RL. Preoperative hair removal: a random prospective study of shaving versus clipping. South Med J. 1982 Jul;75(7):799-801. Court-Brown CM. Preoperative skin depilation and its effect on postoperative wound infections. J R Coll Surg Edinb. 1981 Jul;26(4):238-41. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal--a systematic literature review. AORN J. 2002 May;75(5):928-38, 940. Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg. 1992 Feb;53(2):301-5. Powis SJ, Waterworth TA, Arkell DG. Preoperative skin preparation: clinical evaluation of depilatory cream. Br Med J. 1976 Nov 13;2(6045):1166-8. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971 Mar;121(3):251-4. Tanner J, Moncaster K, Woodings D. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004122. Thur de Koos P, McComas B. Shaving versus skin depilatory cream for preoperative skin preparation. A prospective study of wound infection rates. Am J Surg. 1983 Mar;145(3):377-8.

Summary of Endorsement Review

• Year of Most Recent Endorsement Review: 2012
  
  
• Project for Most Recent Endorsement Review: Surgery
  
  
• Review for Importance: The evidence supports the measure; however, at a mean performance level of 96 percent and just over 7 percent of reporting centers with rates below 100 percent, the measure is at a high level of performance.
  
  
• Review for Scientific Acceptability: The Committee stated that the validity testing of the measure could be improved, and the measure did not present disparity data.
  
  
• Review for Usability: The measure is in wide use. It was noted that this measure was harmonized with measure 0301: Surgery patients with appropriate hair removal.
  
  
• Review for Feasibility: Required data is generated as part of care and does not require additional sources.
  
  
• Endorsement Committee Recommendation: This measure has high performance in the reporting populations. It would be appropriate to consider reporting the measure as part of a surgical bundle.
  
  
• Endorsement Public Comments: Commenters were not in support of this measure because they believed that 100 percent compliance could occur with the removal of razors from the operating room. The Steering Committee's support for continuing this measure in active status was based on the intent to increase the number of ASCs that report the measure to both drive and assess accomplishment of the measure. Absent evidence to the contrary, razors continue to be an acceptable method for preoperative removal of scrotal hair and scalp hair in select circumstances. The exclusion of patients who shave themselves does not diminish capability of the measure to assess ASC performance. In a measure assessing the relationship of method of hair removal to post-operative infection, self-shaving would be an appropriate consideration.
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: This measure assesses days spent in acute care after discharge from an acute care setting for a pneumonia hospitalization to provide a patient-centered assessment of the post-discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow-up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post-discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with pneumonia by collectively measuring a set of adverse outcomes that can occur post-discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post-discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day-count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk-standardized by subtracting the expected number of acute care days from the predicted number. The risk-standardized days of acute care are multiplied by 100 to represent risk-standardized days of events per 100 admissions.
  
  
• Numerator: The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217-99220 or 99234-99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30-day post-discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30-day readmission measure for pneumonia.
  
  
• Denominator: The target population for this measure is patients aged 65 years and older hospitalized for pneumonia and who are either Medicare Fee-for-Service (FFS) beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: -Having a principal discharge diagnosis of pneumonia; -Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65 or over; -Discharged from non-federal acute care hospitals or VA hospitals alive; -Not transferred to another acute care facility; -and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0, and 488.11; ICD-10-CM codes J120, J121, J122, J1281, J1289, J129, J13, J181, J150, J151, J14, J154, J154, J153, J154, J1520, J1521, J1521, Z16, J1529, J158, J155, J156, A481, J158, J159, J157, J160, J168, J180, J189, J1100, J129, J09119).
  
  
• Exclusions: This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post-discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non-VA hospitals).
  
  
• HHS NQS Priority: Communication and Care Coordination
  
  
• HHS Data Source: Administrative Claims
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.
  • Impact on quality of care for patients:This measure would address any return by a patient to an acute care setting including observation stays and emergency department visits. ED visits are a substantial portion of post-discharge acute care use. Studies have shown that 9.5% of patients return to the ED within 30 days of discharge and around 12% are discharged from the ED without being readmitted and would therefore not be included in the current readmission measure in IQR. Additionally, the use of observation stays has risen dramatically-from 2001-2008 there was a three-fold increase in the observation status. The Office of the Inspector General found that Medicare beneficiaries have 1.5 million observation stays annually.
  
  
  
• Does the measure address a program goal or objective? Yes. This is a high impact measure that will improve both quality and efficiency of care and is meaningful to consumers. Any need to return to an acute care setting is impactful to a patient's quality of life. Additionally, there is evidence that keeping patients in observation status have negative financial and quality of life impacts on patients.
  
  
• Is this a high-value measure? Yes. . Pneumonia is the second leading cause of hospitalizations among adults over 65 years old. This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.
  
  
• Does this measure fill a gap in the program measure set? Yes.. This measure would fill a previously identified gap around care coordination.
  
  
• Measure development status: Field testing
  
  
• Is the measure fully tested for the program's setting and level of analysis? No. This measure is in beta 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)? Yes. The measure is entirely derived from Medicare FFS claims data, and unlikely to be burdensome to calculate.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  

Rationale for measure provided by HHS
The goal of this measure is to improve patient outcomes by providing patients, physicians, and hospitals with information about hospital-level, risk-standardized outcomes following hospitalization for pneumonia. Measurement of patient outcomes allows for a broad view of quality of care that cannot be captured entirely by individual process-of-care measures. Safely transitioning patients from hospital to home requires a complex series of tasks which would be cumbersome to capture individually as process measures: timely and effective communication between providers, prevention of and response to complications, patient education about post-discharge care and self-management, and timely follow-up, and more. Inadequate transitional care contributes to a variety of adverse outcomes post-discharge, including readmission, need for observation, and emergency department evaluation. There already exist measures for readmission, but there are no current measures for ED utilization and observation stay. It is thus difficult for providers and consumers to gain a complete picture of post-discharge outcomes. Moreover, separately reporting each outcome encourages “gaming,” such as recategorizing readmission stays as observation stays to avoid a readmission outcome. By constructing a composite of outcomes that are important to patients, we can produce a more complete picture of post-discharge outcomes that better informs consumers about care quality and incentivizes global improvement in outcomes. Pneumonia results in approximately 1.2 million hospital admissions each year and accounts for more than $10 billion annually in hospital expenditures. Among patients over 65 years of age, it is the second leading cause of hospitalization, and is the leading infectious cause of death (Lindenauer et al., 2011). Approximately 20% of pneumonia patients were rehospitalized within thirty days, representing the second-highest proportion of all rehospitalizations at 6.3% (Jencks et al., 2009). Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some readmissions are unavoidable, they may also result from poor quality of care or inadequate transitional care. Transitional care includes effective discharge planning, transfer of information at the time of discharge, patient assessment and education, and coordination of care and monitoring in the post-discharge period. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30-day) readmission rates for a wide range of conditions including pneumonia (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Dean et al., 2006). Several studies also have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. ED visits represent a significant proportion of post-discharge acute care utilization. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013). Additionally, over the past decade, the use of observation stays has rapidly increased. Specifically, between 2001 and 2008, the use of observation services increased nearly three-fold (Venkatesh et al., 2011) and significant variation has been demonstrated in the use of observation services for conditions such as chest pain (Schuur et al., 2011). These rising rates of observation stays among Medicare beneficiaries have gained the attention of patients

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: Median time from emergency department (ED) arrival to provider evaluation for individuals triaged at the two highest levels based on a five-level triage system (e.g., triaged as “immediate” or “emergent”).
  
  
• Numerator: Measure Observation 1: Median time (in minutes) from ED arrival to Qualified Provider Contact for Emergency Department patients triaged with an acuity level of "1-immediate". Measure Observation 2: Median time (in minutes) from ED arrival to Qualified Provider Contact for Emergency Department patients triaged with an acuity level of "2-emergent".
  
  
• Denominator: Measure Population: Any emergency department encounter for which individuals with a triage score of “1-Immediate” or "2-Emergent" based on a 5-level triage system.
  
  
• Exclusions: ED visit for trauma
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: EHR
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Encourage continued development
  
  
• Preliminary analysis summary
  • Contribution to program measure set:MAP has previously stressed the importance of ED throughput measures as important markers of efficiency and safety which can dramatically impact patient experience.  This measure in particular would address severely ill patients being admitted to the ED.
  • Impact on quality of care for patients:This is a high impact measure that reviews the time it took for a severely ill patient with the highest-level triage score to be evaluated by a provider. Implementing this measure could help improve an important aspect of patient safety and experience.
  
  
  
• Does the measure address a program goal or objective? Yes. This measure would be meaningful to patients. ED wait times are an important aspect of patient experience and timely evaluation is an important safety issue. 
  
  
• Is this a high-value measure? Yes. This measure could help promote a culture of safety. MAP has previously stressed the importance of ED throughput measures as important markers of efficiency and safety which can dramatically impact patient experience. 
  
  
• Does this measure fill a gap in the program measure set? Yes.. Yes, while ED throughput is currently addressed in the IQR program, this measure could add valuable detail about the time severely ill patients must wait to be seen.
  
  
• Measure development status: Early development
  
  
• Is the measure fully tested for the program's setting and level of analysis? No. Testing for this measure is still underway.
  
  
• Is the measure currently in use? No. This measure is not in use nor has it been reviewed as an e-Measure for endorsement. 
  
  
• Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. This measure contributes to the efficient use of measurement resources by filling the MAP identified priority gap of creating a culture of safety. This measure is also under review for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program. 
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  

Rationale for measure provided by HHS
This is a new eCQM that assesses a different aspect of ED provider care, and specifically assesses provider timeliness to evaluation. The anticipated effect of implementing this measure would be to reduce the time for high risk patients to be seen by a physician in the emergency department and thereby reduce adverse events (i.e., morbidity and mortality). High-risk individuals are identified by assignment of the highest or most urgent score from a valid triage system.

Measure Specifications

• NQF Number (if applicable): 2633
  
  
• Description: This measure estimates the average risk-adjusted mean change in self-care function between admission and discharge for patients discharged from IRFs.
  
  
• Numerator: The mean change in self-care function.
  
  
• Denominator: Patients discharged from the IRF.
  
  
• Exclusions: Four exclusion criteria apply to the change in self-care function score measure: 1) Patients with incomplete stays: It can be challenging to gather accurate discharge functional status data for patients who experience incomplete stays. Patients with incomplete stays include patients who are unexpectedly discharged to an acute-care setting (Inpatient Prospective Payment System, Critical Access Hospital, Inpatient Psychiatric Hospital, or LTCH) due to a medical emergency; patients who die; patients who leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients who are independent with CARE self-care activities at the time of admission: Patients who are independent with the CARE self-care items at the time of admission are assigned the highest score on all the self-care items, and thus, would not be able to show functional improvement on this same set of items at discharge. 3) Patients in coma, persistent vegetative state, complete teraplegia, and locked-in syndrome are excluded, because they may have limited or less predictable self-care improvement. 4) Patients younger than age 21.
  
  
• HHS NQS Priority: Patient and Family Engagement
  
  
• HHS Data Source: Other
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. Functional status is also a priority area for measurement for the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.
  • Impact on quality of care for patients:The primary goal in rehabilitation is function improvement. The change in function scores represent the effectiveness of the rehabilitation care provided to patients. This measure will inform IRF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function.
  
  
  
• Does the measure address a program goal or objective? Yes. This measure estimates the change in self-care score among IRF patients. Improvement in functional status is the primary goal of rehabilitation and is a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. 
  
  
• Is this a high-value measure? Yes. This is an outcome measure that estimates the risk-adjusted mean change in self-care score between admission and discharge for Inpatient Rehabilitation Facility (IRF) Medicare patients.
  
  
• Does this measure fill a gap in the program measure set? Yes. Currently, there are no other functional outcome measures in the program that assess change in self-care score for medical rehabilitation patients.
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes. The datasets used for the testing of this quality measure are: 1) the CARE Tool data collected during the Post-Acute Care Payment Reform Demonstration and 2) Medicare claims data.Testing for this quality measure involved several types of item- and scale-level reliability and validity analyses.
  
  
• Is the measure currently in use? No. This is a new measure. No prior use data is available.
  
  
• Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? No. It addresses a priority measurement area identified by the MAP Duals Workgroup.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has been submitted for endorsement under the PFCC phase 2 project.
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Functional and cognitive status assessment
  
  
• IMPACT Act Domain addressed by the measure: Functional status, cognitive function, and changes in function and cognitive function;
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure "Compliance with Ventilator Process Elements during LTCH stay" is a paired quality measure (QM#1 and QM#2); it assesses facility-level compliance with Ventilator Process Elements for eligible patients in the LTCH setting. Quality Measure #1: Compliance with Tracheostomy Collar Trial (TCT) or Spontaneous Breathing Trial (SBT) by the end of the first calendar day following admission to the LTCH. Quality Measure #2: Compliance with TCT or SBT during LTCH stay - day 2 through discharge date/ date when patient is fully weaned. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Tracheostomy Collar Trial: Trial of unassisted breathing via a tracheostomy collar (mask) with aerosol (mist), administered to patients with tracheostomy tubes. iii. Spontaneous Breathing Trial: Trial of unassisted breathing for at least X time period and full ventilator support at night, administered to patients with endotracheal tubes.
  
  
• Numerator: QM#1: The percentage of patients who are admitted to a LTCH on invasive mechanical ventilation and for whom tracheostomy collar trial (TCT) or Spontaneous Breathing Trial (SBT) was assessed, ordered, and performed by the end of the first calendar day following admission to the LTCH. (a) Percentage of patients on invasive mechanical ventilation prior to admission for whom TCT or SBT was assessed, ordered and performed within 24 hours of admission. (b) Percentage of patients for whom TCT or SBT was not assessed, ordered and performed within 24 hours of admission. (c) Percentage of patients for whom TCT or SBT within 24 hours of admission was deemed medically inappropriate. QM#2: The total number of patient ventilator-days for patients discharged (unplanned discharge, planned discharge, death) during the reporting period who were admitted to the LTCH requiring invasive mechanical ventilation. (a) Percentage of ventilator days that TCT or SBT was assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (b) Percentage of ventilator days that TCT or SBT was not assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (c) Percentage of ventilator days that TCT or SBT was deemed medically inappropriate during each day of invasive mechanical ventilation LTCH stay.
  
  
• Denominator: All patients admitted to the LTCH requiring invasive mechanical ventilation support of any duration at the time of admission to the LTCH during the reporting period. If a patient has more than one LTCH stay during the reporting period, then, each admission will be included in the measure calculation and reporting for QM#1. For QM#2, the patient population includes all discharged patients who are admitted to a LTCH on invasive mechanical ventilation. If a patient has more than one LTCH stay during the reporting period, then, each discharge will be included in the measure calculation and reporting for QM#2. Denominator for QM#2 is the total number of patient ventilator-days for patients discharged (unplanned discharge, planned discharge, death) during the reporting period who were admitted to the LTCH requiring invasive mechanical ventilation support of any duration at the time of admission to the LTCH.
  
  
• Exclusions: Patients identified as unweanable at the time of admission to an LTCH are excluded. These include (a) patients who are chronically ventilated (i.e., who have been on invasive mechanical ventilator support for more than 180 days prior to admission to the short-stay acute care hospital (if it this stay preceded the current LTCH stay) or prior to admission to the LTCH, whichever is earlier) [this would include patients on a ventilator due to cerebral palsy since childhood); or (b) patients with an acute or chronic condition (for e.g., irreversible neurological injury or disease or dysfunction such as ALS, or high (C2) spinal cord injury that has rendered the patient unweanable. This measure also excludes patients admitted to LTCH and requiring on non-invasive mechanical ventilation. LTCHs with denominator counts of less than 20 in the sample during the reporting period will be excluded from public reporting, owing to small sample size.
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: LTCH CARE Data Set
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Encourage continued development
  
  
• Preliminary analysis summary
  • Contribution to program measure set:The measure addresses an important patient safety priority for LTCHs. It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia. There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs. Further development is encouraged.
  • Impact on quality of care for patients:It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia.  There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs.
  
  
  
• Does the measure address a program goal or objective? Yes. The measure addresses an important patient safety priority for LTCHs. It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia.  There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs.
  
  
• Is this a high-value measure? Yes. This is a process measure that assesses facility-level compliance with Ventilator Process Elements for eligible patients in the LTCH setting. Assessing compliance with Ventilator Process Elements can help identify when interventions are necessary to decrease incidence of ventilator-associated pneumonia and improve ventilator care.
  
  
• Does this measure fill a gap in the program measure set? Yes. Including measures related to ventilator has been identified was identified as high priority for the LTCH QRP.
  
  
• Measure development status: Early development
  
  
• Is the measure fully tested for the program's setting and level of analysis? No. Measure development contract awarded but development has not started.
  
  
• Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. None
  
  
• Is the measure currently in use? No. Not currently being used in a program.
  
  
• Does the MUC contribute to alignment and efficient use of measurement resources (burden and cost of measurement)? Yes. VAP is associated with approximately 10K in extra costs per patient who develops it.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Infection rates
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
1. There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care 2. VAP and VAE is associated with substantial morbidity, mortality, and excess healthcare costs. 3. Patients who develop VAP incur an extra $10K (2005) in hospital costs (Sadfar 2005). 4. Based on an analysis of CY 2004 MedPAR data for Medicare beneficiaries, 25% of ventilated patients in LTCHs acquired VAP (Buczko 2009).

Measure Specifications

• NQF Number (if applicable): 1822
  
  
• Description: This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.
  
  
• Numerator: All patients, regardless of age, with painful bone metastases, and no previous radiation to the same anatomic site who receive EBRT with any of the following recommended fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns, 8Gy/1fxn.
  
  
• Denominator: All patients with painful bone metastases and no previous radiation to the same anatomic site who receive EBRT
  
  
• Exclusions: The medical reasons for denominator exclusions are: 1) Previous radiation treatment to the same anatomic site; 2) Patients with femoral axis cortical involvement greater than 3 cm in length; 3) Patients who have undergone a surgical stabilization procedure; and 4) Patients with spinal cord compression, cauda equina compression or radicular pain
  
  
• HHS NQS Priority: Effective Prevention and Treatment
  
  
• HHS Data Source: EHR, Paper Medical Record
  
  
• Measure Type: Process
  
  
• Steward: American Society for Radiation Oncology
  
  
• Endorsement Status: Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure would address a gap in cancer care in the OQR measure set.
  • Impact on quality of care for patients:External beam radiation can help provide patients with pain relief.  This measure has a demonstrated performance gap and would would begin to expand cancer care measurement to settings beyond the PPS-exempt cancer hospitals.
  
  
  
• Does the measure address a program goal or objective? Yes. There is a strong evidence base for this measure. This measure would address the goal of including measures meaningful to patients as pain relief is a very important aspect of quality for consumers.
  
  
• Is this a high-value measure? Yes. This measure is high impact with strong supportive evidence base for this intervention, with nearly a 20% performance gap. 
  
  
• Does this measure fill a gap in the program measure set? Yes.. MAP has previously stressed the importance of expanding cancer care measurement to programs outside of the PPS-Exempt Cancer Hospital Quality Reporting Program.
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the facility level.
  
  
• 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 begin to expand cancer care measurement to settings beyond the PPS-exempt cancer hospitals.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
  
  

Rationale for measure provided by HHS
The measure is developed from the recommendations by the clinical-practice guideline. This measure is intended to close the gap in the demonstrated treatment variation and ensure the use of an appropriate fractionation schedule. The measure also takes into account the effective schedule for relieving pain from bone metastases, patient preferences and the time and cost effectiveness. Population: The measure is applicable to all patients, regardless of age with a diagnosis of painful bone metastases who are prescribed EBRT unless there is a documented exclusion as specified. 1. Jeremic B, Shibamoto Y, Acimovic L, et al. A randomized trial of three single-dose radiation therapy regimens in the treatment of metastatic bone pain. Int J Radiat Oncol Biol Phys 1998;42:161–167. 2. Bone Pain Trial Working Party. 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: Randomized comparison with a multifraction schedule over 12 months of patient follow-up. Radiother Oncol 1999;52:111–121. 3. Roos D, Turner S, O’Brien P, et al. Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05). Radiother Oncol 2005;75: 54–63. 4. Hartsell W, Konski A, Scott C, et al. Randomized trial of short versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 2005;97:798–804.

Summary of Endorsement Review

• Year of Most Recent Endorsement Review: 2012
  
  
• Project for Most Recent Endorsement Review: Cancer
  
  
• Review for Importance: The measure has high impact. There is a high opportunity for improvement, with nearly a 20% performance gap noted. The measure represents quality care. There is a strong supportive evidence base for this intervention.
  
  
• Review for Scientific Acceptability: The measure is well specified and exclusions are appropriate, except the patient reason exclusions. The Steering Committee asked the developer to remove those exclusions, and the developer agreed to do so. The reliability testing for the measure is appropriate and demonstrates the reliability of the measure. Face validity of the measure was demonstrated.
  
  
• Review for Usability: The developer has provided a detailed plan for representation of measure results, usability for QI, and public reporting of the measure through PQRS.
  
  
• Review for Feasibility: Data elements are in EHR and generated during the provision of care.
  
  
• Endorsement Committee Recommendation: Endorse. The Steering Committee stated that this measure represents good care with a strong evidence base supporting the focus of the measure. The patients affected by this measure suffer from severe pain and the intervention will help alleviate their discomfort.
  
  
• Endorsement Public Comments: While commenters indicated general support for the measure, several issues were raised including the burden of data collection data on whether a case meets exclusion criteria, and patient preference for other types of treatment.
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
  
  
• Numerator: Patients who are referred to hospice care
  
  
• Denominator: All patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis
  
  
• Exclusions: Documentation of patient reason(s) for not referring to hospice care (e.g., patient declined, other patient reasons)
  
  
• HHS NQS Priority: Patient and Family Engagement
  
  
• HHS Data Source: Claims, Registry
  
  
• Measure Type: Process
  
  
• Steward: Renal Physicians Association; joint copyright with American Medical Association - Physician Consortium for Performance Improvement
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Public-facing clinician web page
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Patients and consumers are interested in the quality of patient-centered care.
  • Impact on quality of care for patients:Patient selection may foster quality improvement.
  
  
  
• Does the measure address a program goal or objective? Yes. Measure of patient-centered care of interest to consumers and patients.
  
  
• Is this a high-value measure? Yes. MAP Clinician Workgroup Guiding Principles
  
  
• Measure development status: Field testing
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  

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

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record.
  
  
• Numerator: Patients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview at least once during COT.
  
  
• Denominator: All patients 18 and older prescribed opiates for longer than six weeks duration.
  
  
• Exclusions: None
  
  
• HHS NQS Priority: Effective Prevention and Treatment
  
  
• HHS Data Source: Registry
  
  
• Measure Type: Process
  
  
• Steward: American Academy of Neurology
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Spreadsheet
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Narrow-focused process measure. A composite of several measures addressing opioid misuse would be more meaningful for the public-facing clinician web page.
  
  
  
• Does the measure address a program goal or objective? Yes.
  
  
• Measure development status: Fully developed
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  

Rationale for measure provided by HHS
Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low‐quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low‐quality evidence). A benefit‐to‐harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low‐quality evidence).

Measure Specifications

• NQF Number (if applicable): 1523
  
  
• Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers.
  
  
• Numerator: Mortality following elective open repair of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
  
  
• Denominator: All elective open repairs of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
  
  
• Exclusions: Exclusion Statement: = 6 cm minor diameter - men = 5.5 cm minor diameter - women Symptomatic AAAs that required urgent/emergent (non-elective) repair
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: Registry
  
  
• Measure Type: Outcome
  
  
• Steward: The Society for Vascular Surgery
  
  
• Endorsement Status: Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Public-facing clinician web page
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Outcome measure that consumers and patients can use to compare providers.
  • Impact on quality of care for patients:Patient selection may foster quality improvement.
  
  
  
• Does the measure address a program goal or objective? Yes. Measure of interest to consumers and patients.
  
  
• Is this a high-value measure? Yes. MAP Clinician Workgroup Guiding Principles
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
  
  

Rationale for measure provided by HHS
Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.

Summary of Endorsement Review

• Year of Most Recent Endorsement Review: 2012
  
  
• Project for Most Recent Endorsement Review: Surgery
  
  
• Review for Importance: The measure provides important outcome data. More AAA repairs are being conducted; although, they may not be medically necessary. However, the data provided in the measure included both small and large aneurysms, despite the stated measure’s focus on only small AAAs. High mortality levels may encourage a process review.
  
  
• Review for Scientific Acceptability: The Committee described the importance of extending the measure to 30-day mortality to identify adverse outcomes. The Committee stated the numerator time window, while verbally explained satisfactorily, could be confusing to users.
  
  
• Review for Usability: The data used for the measure is drawn from registry data that includes both claims and chart abstracted data thus is usable for registry participants although for non-registry participants, the data would prove challenging to collect.
  
  
• Review for Feasibility: The registry group from which data for this measure is drawn is about 10 hospitals thus information about feasibility is limited both in terms of the number of facilities in which tested and testing with only registry data. At present there is no mechanism for identifying small aneurysms with administrative data. The developer is working to develop CPT II codes that would allow aneurysm size to be captured and reported with administrative data. This would require new/additional specifications for the measure. It was noted that the measure could be revised and limited to mortality unrelated to aneurysm size that could be collected using administrative data; this would require further modification of the measure.
  
  
• Endorsement Committee Recommendation: Endorse
  
  
• Endorsement Public Comments: Supportive of this outcome measure that is specified to be applied at all applicable levels of measurement
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
  
  
• Numerator: Patients who are referred to hospice care
  
  
• Denominator: All patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis
  
  
• Exclusions: Documentation of patient reason(s) for not referring to hospice care (e.g., patient declined, other patient reasons)
  
  
• HHS NQS Priority: Patient and Family Engagement
  
  
• HHS Data Source: Claims, Registry
  
  
• Measure Type: Process
  
  
• Steward: Renal Physicians Association; joint copyright with American Medical Association - Physician Consortium for Performance Improvement
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Encourage continued development
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Process measure addresses patient-centered care, end of life care and is a priority for dual eligibles.
  • Impact on quality of care for patients:Hospice care has been shown to improve quality of life at the end of life, offers personalized care with dignity, respects patient's wishes and avoids costs of futile and unnecessary care.
  
  
  
• Does the measure address a program goal or objective? Yes. Process measure that focuses on patient- and family-centered care and end-of life care.
  
  
• Is this a high-value measure? Yes. A patient-centered care measure.
  
  
• Does this measure fill a gap in the program measure set? Yes. MAP Clinician Workgroup identified palliative and end of life care as a gap area.
  
  
• Measure development status: Field testing
  
  
• Is the measure fully tested for the program's setting and level of analysis? No. Testing at individual practice; group practice level
  
  
• Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.
  
  
• Is the measure currently in use? Yes. QCDR
  
  
• 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. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  

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

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record.
  
  
• Numerator: Patients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview at least once during COT.
  
  
• Denominator: All patients 18 and older prescribed opiates for longer than six weeks duration.
  
  
• Exclusions: None
  
  
• HHS NQS Priority: Effective Prevention and Treatment
  
  
• HHS Data Source: Registry
  
  
• Measure Type: Process
  
  
• Steward: American Academy of Neurology
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Patient safety measure screening for opioid misuse in all patients regardless of diagnosis. The measure can be used by a wide range of clinicians. Priority for dual eligibles. CONDITION: submit to NQF for endorsement.
  • Impact on quality of care for patients:If interventions to avoid opioid misuse are implemented as a result of the screening evaluation, patients would not suffer from this growing problem.
  
  
  
• Does the measure address a program goal or objective? Yes. Patient safety measure screening for risk of opioid miuse.
  
  
• Is this a high-value measure? No. Screening measures alone, without follow-up actions, are less likely to improve quality for care.
  
  
• Does this measure fill a gap in the program measure set? Yes. MAP Clinician Workgroup identified opioid misuse as a gap area.
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes. No information
  
  
• 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 high-priority quality issue in the dual eligible beneficiary population.  This measure applies to a broader population than MUC X3770.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  

Rationale for measure provided by HHS
Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low‐quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low‐quality evidence). A benefit‐to‐harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low‐quality evidence).

Measure Specifications

• NQF Number (if applicable): 1523
  
  
• Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers.
  
  
• Numerator: Mortality following elective open repair of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
  
  
• Denominator: All elective open repairs of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
  
  
• Exclusions: Exclusion Statement: = 6 cm minor diameter - men = 5.5 cm minor diameter - women Symptomatic AAAs that required urgent/emergent (non-elective) repair
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: Registry
  
  
• Measure Type: Outcome
  
  
• Steward: The Society for Vascular Surgery
  
  
• Endorsement Status: Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:High-level outcome measure that is fully developed and NQF-endorsed. The measure complements existing measure PQRS#258 "Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)"
  • Impact on quality of care for patients:Measurement and quality improvement activities to reduce mortality will save lives.
  
  
  
• Does the measure address a program goal or objective? Yes. High-value outcome measure; addresses NQS priority of making care safer by reducing harm caused in the delivery of care.
  
  
• Is this a high-value measure? Yes. Outcome measure
  
  
• Does this measure fill a gap in the program measure set? Yes. Outcome measure for major surgery
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at clinician, group, practice and facility levels.
  
  
• Is the measure currently in use? Yes. Vascular Study Group of New England registry
  
  
• Does a review of its performance history raise any concerns? No.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
  
  

Rationale for measure provided by HHS
Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.

Summary of Endorsement Review

• Year of Most Recent Endorsement Review: 2012
  
  
• Project for Most Recent Endorsement Review: Surgery
  
  
• Review for Importance: The measure provides important outcome data. More AAA repairs are being conducted; although, they may not be medically necessary. However, the data provided in the measure included both small and large aneurysms, despite the stated measure’s focus on only small AAAs. High mortality levels may encourage a process review.
  
  
• Review for Scientific Acceptability: The Committee described the importance of extending the measure to 30-day mortality to identify adverse outcomes. The Committee stated the numerator time window, while verbally explained satisfactorily, could be confusing to users.
  
  
• Review for Usability: The data used for the measure is drawn from registry data that includes both claims and chart abstracted data thus is usable for registry participants although for non-registry participants, the data would prove challenging to collect.
  
  
• Review for Feasibility: The registry group from which data for this measure is drawn is about 10 hospitals thus information about feasibility is limited both in terms of the number of facilities in which tested and testing with only registry data. At present there is no mechanism for identifying small aneurysms with administrative data. The developer is working to develop CPT II codes that would allow aneurysm size to be captured and reported with administrative data. This would require new/additional specifications for the measure. It was noted that the measure could be revised and limited to mortality unrelated to aneurysm size that could be collected using administrative data; this would require further modification of the measure.
  
  
• Endorsement Committee Recommendation: Endorse
  
  
• Endorsement Public Comments: Supportive of this outcome measure that is specified to be applied at all applicable levels of measurement
  
  

Measure Specifications

• NQF Number (if applicable): 2510
  
  
• Description: This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions. A risk-adjusted readmission rate for each facility is calculated as follows: Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility’s effects on readmission rates. Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate. For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures. The measure specifications are designed to harmonize with CMS’s hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM.
  
  
• Numerator: The numerator is defined as the risk-adjusted estimate of the number of unplanned readmissions that occurred within 30 days from discharge from the prior proximal acute hospitalization.
  
  
• Denominator: The denominator includes all patients who have been admitted to a SNF within one day of discharge from a prior proximal hospitalization, taking denominator exclusions into account.
  
  
• Exclusions: Numerator exclusions: We exclude for planned readmissions as per the HWR measure. Denominator exclusions: The following are excluded from the denominator: 1. SNF stays where the patient had one or more intervening post-acute care (PAC) admissions (inpatient rehabilitation facility [IRF] or long-term care hospital [LTCH]) which occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge, within the 30-day risk window. Also excluded are SNF admissions where the patient had multiple SNF admissions after the prior proximal hospitalization, within the 30-day risk window. 2. SNF stays with a gap of greater than 1 day between discharge from the prior proximal hospitalization and the SNF admission. 3. SNF stays where the patient did not have at least 12 months of FFS Medicare enrollment prior to the proximal hospital discharge (measured as enrollment during the month of proximal hospital discharge and for the 11 months prior to that discharge). 4. SNF stays in which the patient did not have FFS Medicare enrollment for the entire risk period (measured as enrollment during the month of proximal hospital discharge and the month following the month of discharge). 5. SNF stays in which the principal diagnosis for the prior proximal hospitalization was for the medical treatment of cancer. Patients with cancer whose principal diagnosis from the prior proximal hospitalization was for other diagnoses or for surgical treatment of their cancer remain in the measure. 6. SNF stays where the patient was discharged from the SNF against medical advice. 7. SNF stays in which the principal primary diagnosis for the prior proximal hospitalization was for “rehabilitation care; fitting of prostheses and for the adjustment of devices”.
  
  
• HHS NQS Priority: Communication and Care Coordination
  
  
• HHS Data Source: Administrative Claims
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Not Endorsed
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA). MAP had reviewed and supported the direction of the measure concept in the 2013 pre-rulemaking. This measure is currently under review for endorsement and was recently finalized for use in MSSP in the 2015 PFS rule.
  • Impact on quality of care for patients:There is evidence available related to the structure-process-outcome relationship specifically for reducing hospital readmissions among SNF patients. The evidence suggests there are factors that vary at the organizational level, which impact patient care and could be altered to improve rates of hospital readmission. Once hospital readmission rates are measured, the onus will be on the providers to identify which factors are most likely to impact improvement and then design, implement and monitor processes to address these factors.
  
  
  
• Does the measure address a program goal or objective? Yes. This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA).The NQF Admissions/Readmissions Standing Committee noted that this measure would encourage care coordination and could be easily implemented. The Standing Committee noted a significant performance gap with performance ranging from 11.9 to 41.9 percent.This measure was recommended for NQF-endorsement.
  
  
• Is this a high-value measure? Yes. This is an outcome measure that estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization.
  
  
• Does this measure fill a gap in the program measure set? Yes. The legislation mandates that CMS will specify a SNF all-cause all-condition hospital readmission measure by no later than Octoober 1, 2015.
  
  
• Measure development status: Fully developed
  
  
• Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested in the nursing home setting at the facility level of analysis.
  
  
• 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. In the 2013 pre-rulemaking, MAP had supported the direction of the measure concept. MAP had noted that a consolidated, evidence-based readmission measure should be developed to promote alignment and shared responsibility across the care continuum and PAC/LTC settings and the measure should beappropriately risk adjusted to accommodate variations in population.The NQF Admissions/Readmissions Standing Committee noted that this measures approach to capturing readmissions is consistent with other CMS readmission measures.This measure was recentlyfinalized for use in MSSP in the 2015 PFS rule.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is in final stages of review for endorsement.
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Avoidable admissions
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
The Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP measure.

Program Index

• Physician Quality Reporting System (PQRS)  
  
  
• Physician Compare 
  
  
• Hospital Inpatient Quality Reporting 
  
  
• Hospital Outpatient Quality Reporting Program 
  
  
• Ambulatory Surgical Center Quality Reporting Program 
  
  
• Skilled Nursing Facility Value-Based Purchasing Program 
  
  
• Inpatient Rehabilitation Facility Quality Reporting Program 
  
  
• Long-Term Care Hospital Quality Reporting Program 
  
  

Full Program Summaries

Program History and Structure: PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).

Current Program Measure Information: In 2012-2014, EPs could receive an incentive payment equal to a percentage (2% in 2010, gradually decreasing to 0.5% in 2014) of the EP’s estimated total allowed charges for covered Medicare Part B services under the Medicare Physician Fee Schedule. Beginning in 2015, EPs and group practices that do not satisfactorily report data on quality measures will receive a reduction (1.5% in 2015 and 2% in subsequent years) in payment.

High Priority Domains for Future Measure Consideration: The goal of the PQRS program is to encourage widespread participation by EPs to report quality information. In 2012, only 36% of EPs satisfactorily submitted quality information to PQRS.

Measure Requirements:

• To encourage widespread participation many measures are needed for the variety of EPs specialties and sub-specialties.
• The measures chosen by EPs to submit for PQRS will be reported on Physician Compare and used to determine the Value Based Payment Modifier, therefore all PQRS measures will be used for accountability purposes.
• Include more high value measures, e.g., outcomes, patient-reported outcomes, composites, intermediate outcomes, process measures close to outcomes, cost and resource use measures, appropriate use measures, care coordination measures, patient safety, etc.
• Include NQF-endorsed measures relevant to clinician reporting to encourage engagement Measures selected for the program that are not NQF-endorsed should be submitted for endorsement.
• For measures that are not endorsed, include measures under consideration that are fully specified and that:
• Support alignment (e.g., measures used in other programs, registries)
• Are outcome measures that are not already addressed by outcome measures included in the program
• Are clinically relevant to specialties/subspecialties that do not currently have clinically relevant measures

Current Measures:
The proposed measures for this program include:

• Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
• Depression Response at Twelve Months- Progress Towards Remission
• Documentation of Current Medications in the Medical Record
• Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls
• Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision (#393)
• Influenza immunization
• Measure #1: Diabetes: Hemoglobin A1c Poor Control
• Measure #100: Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
• Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
• Measure #104: Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients
• Measure #108: Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
• Measure #110: Preventive Care and Screening: Influenza Immunization
• Measure #111: Pneumonia Vaccination Status for Older Adults
• Measure #113: Colorectal Cancer Screening
• Measure #116: Antibiotic Treatment for Adults With Acute Bronchitis: Avoidance of Inappropriate Use
• Measure #117: Diabetes: Eye Exam
• Measure #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
• Measure #119: Diabetes: Medical Attention for Nephropathy
• Measure #12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
• Measure #121: Adult Kidney Disease: Laboratory Testing (Lipid Profile)
• Measure #122: Adult Kidney Disease: Blood Pressure Management
• Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy  - Neurological Evaluation
• Measure #127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear
• Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
• Measure #131: Pain Assessment and Follow-Up
• Measure #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
• Measure #137: Melanoma: Continuity of Care - Recall System
• Measure #138: Melanoma: Coordination of Care
• Measure #14: Age-Related Macular Degeneration (AMD): Dilated Macular Examination
• Measure #140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
• Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
• Measure #143: Oncology: Medical and Radiation - Pain Intensity Quantified
• Measure #144: Oncology: Medical and Radiation - Plan of Care for Pain
• Measure #145: Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
• Measure #146: Radiology: Inappropriate Use of Probably Benign" Assessment Category in Mammography Screening"
• Measure #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
• Measure #154: Falls: Risk Assessment
• Measure #155: Falls: Plan of Care
• Measure #156: Oncology: Radiation Dose Limits to Normal Tissues
• Measure #160: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
• Measure #163: Diabetes: Foot Exam
• Measure #164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation
• Measure #165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
• Measure #166: Coronary Artery Bypass Graft (CABG): Stroke
• Measure #167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
• Measure #168: Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
• Measure #172: Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula
• Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening
• Measure #176: Rheumatoid Arthritis (RA): Tuberculosis Screening
• Measure #177: Rheumatoid Arthritis: Periodic Assessment of Disease Activity
• Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment
• Measure #179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
• Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management
• Measure #181: Elder Maltreatment Screen and Follow-Up Plan
• Measure #182: Functional Outcome Assessment
• Measure #183: Hepatitis C: Hepatitis A Vaccination
• Measure #185: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use
• Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy
• Measure #19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
• Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
• Measure #192: Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
• Measure #193: Perioperative Temperature Management
• Measure #194: Oncology: Cancer Stage Documented
• Measure #195: Radiology: Stenosis Measurement in Carotid Imaging Reports
• Measure #204: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
• Measure #205: HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
• Measure #21: Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin
• Measure #217: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
• Measure #218: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
• Measure #219: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments
• Measure #22: Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
• Measure #220: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
• Measure #221: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
• Measure #222: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments
• Measure #223: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments
• Measure #224: Melanoma: Overutilization of Imaging Studies in Melanoma
• Measure #225: Radiology: Reminder System for Screening Mammograms
• Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• Measure #23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
• Measure #236: Controlling High Blood Pressure
• Measure #238: Use of High-Risk Medications in the Elderly
• Measure #24: Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
• Measure #240: Childhood Immunization Status
• Measure #242: Coronary Artery Disease (CAD): Symptom Management
• Measure #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting
• Measure #249: Barrett's Esophagus
• Measure #250: Radical Prostatectomy Pathology Reporting
• Measure #251: Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients
• Measure #254 : Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
• Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
• Measure #257: Statin Therapy at Discharge after Lower Extremity Bypass (LEB)
• Measure #258: Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)
• Measure #259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)
• Measure #260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
• Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
• Measure #262: Image Confirmation of Successful Excision of Image-Localized Breast Lesion
• Measure #263: Preoperative Diagnosis of Breast Cancer
• Measure #264: Sentinel Lymph Node Biopsy for Invasive Breast Cancer
• Measure #265: Biopsy Follow-Up
• Measure #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
• Measure #270: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
• Measure #271: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment
• Measure #274: Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
• Measure #275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
• Measure #276: Sleep Apnea: Assessment of Sleep Symptoms
• Measure #277: Sleep Apnea: Severity Assessment at Initial Diagnosis
• Measure #278: Sleep Apnea: Positive Airway Pressure Therapy Prescribed
• Measure #279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
• Measure #280: Dementia: Staging of Dementia
• Measure #282: Dementia: Functional Status Assessment
• Measure #283: Dementia: Neuropsychiatric Symptom Assessment
• Measure #284: Dementia: Management of Neuropsychiatric Symptoms
• Measure #285: Dementia: Screening for Depressive Symptoms
• Measure #286: Dementia: Counseling Regarding Safety Concerns
• Measure #287: Dementia: Counseling Regarding Risks of Driving
• Measure #288: Dementia: Caregiver Education and Support
• Measure #289: Parkinson's Disease: Annual Parkinson's Disease Diagnosis Review
• Measure #290: Parkinson's Disease: Psychiatric Disorders or Disturbances Assessment
• Measure #291: Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment
• Measure #292: Parkinson's Disease: Querying about Sleep Disturbances
• Measure #293: Parkinson's Disease: Rehabilitative Therapy Options
• Measure #294: Parkinson's Disease: Parkinson's Disease Medical and Surgical Treatment Options Reviewed
• Measure #303: Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
• Measure #304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
• Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
• Measure #32: Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
• Measure #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
• Measure #322: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
• Measure #323: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
• Measure #324: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
• Measure #325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
• Measure #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
• Measure #327: Pediatric Kidney Disease: Adequacy of Volume Management
• Measure #328: Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL
• Measure #329: Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis
• Measure #33: Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge
• Measure #330: Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days
• Measure #331: Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use)
• Measure #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
• Measure #333: Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
• Measure #334: Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
• Measure #335: Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks
• Measure #336: Maternity Care: Post-Partum Follow-Up and Care Coordination
• Measure #337: Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier
• Measure #338: HIV Viral Load Suppression
• Measure #339: Prescription of HIV Antiretroviral Therapy
• Measure #340: HIV Medical Visit Frequency
• Measure #342: Pain Brought Under Control Within 48 Hours
• Measure #343: Screening Colonoscopy Adenoma Detection Rate
• Measure #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
• Measure #345: Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
• Measure #346: Rate of Postoperative Stroke or Death in Asymptomatic Patients undergoing Carotid Endarterectomy (CEA)
• Measure #347: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital
• Measure #348: HRS-3 Implantable Cardioverter-Defibrillator (ICD) Complications Rate
• Measure #349: Optimal Vascular Composite
• Measure #350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
• Measure #351: Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
• Measure #352: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
• Measure #353: Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
• Measure #354: Anastomotic Leak Intervention
• Measure #355: Unplanned Reoperation within the 30 Day Postoperative Period
• Measure #356: Unplanned Hospital Readmission within 30 Days of Principal Procedure
• Measure #357: Surgical Site Infection (SSI)
• Measure #358: Patient-centered Surgical Risk Assessment and Communication
• Measure #359: Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description
• Measure #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
• Measure #361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
• Measure #362: Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
• Measure #363: Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive
• Measure #364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
• Measure #370: Depression Remission at Twelve Months
• Measure #383: Adherence to Antipsychotics Medications for Individuals with Schizophrenia
• Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate
• Measure #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
• Measure #387: Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
• Measure #388: Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule requiring unplanned vitrectomy)
• Measure #389: Cataract Surgery: Difference Between Planned and Final Refraction
• Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
• Measure #390: Discussion and Shared Decision Making Surrounding Treatment Options
• Measure #391: Follow-Up After Hospitalization for Mental Illness (FUH)
• Measure #392: HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
• Measure #394: Immunizations for Adolescents
• Measure #395:  Lung Cancer Reporting (Biopsy/Cytology Specimens)
• Measure #396:  Lung Cancer Reporting (Resection Specimens)
• Measure #397:  Melanoma Reporting
• Measure #398: Optimal Asthma Control
• Measure #399: Post-Procedural Optimal Medical Therapy Composite (Percutaneous Coronary Intervention)
• Measure #40: Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
• Measure #400: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
• Measure #401: Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis
• Measure #402: Tobacco Use and Help with Quitting Among Adolescents
• Measure #41: Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older
• Measure #43: Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with isolated CABG Surgery
• Measure #44: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
• Measure #46: Medication Reconciliation
• Measure #47: Care Plan
• Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
• Measure #5: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
• Measure #50: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
• Measure #51: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
• Measure #52: Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
• Measure #53: Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting
• Measure #54: Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
• Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy
• Measure #65: Appropriate Treatment for Children with Upper Respiratory Infection (URI)
• Measure #66: Appropriate Testing for Children with Pharyngitis
• Measure #67: Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow
• Measure #68: Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy
• Measure #69: Hematology: Multiple Myeloma: Treatment with Bisphosphonates
• Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
• Measure #70: Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
• Measure #71: Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer
• Measure #72: Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
• Measure #76: Prevention of Central Venous Catheter (CVC)  - Related Bloodstream Infections
• Measure #8: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
• Measure #81: Adult Kidney Disease: Hemodialysis Adequacy: Solute
• Measure #82: Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute
• Measure #84: Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
• Measure #85: Hepatitis C: Hepatitis C Virus (HCV) Genotype Testing Prior to Treatment
• Measure #87: Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment
• Measure #91: Acute Otitis Externa (AOE): Topical Therapy
• Measure #93: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use
• Measure #99: Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
• Pain Assessments and Target Setting for Patients with Osteoarthritis
• Preventive Care and Screening: Influenza Immunization
• Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
• Risk-Adjusted Deep Sternal Wound Infection Rate
• Surgical Site Infection Rate

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

• 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

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

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

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.

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

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

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

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

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

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

• Adverse Drug Events
• Cancer
• Palliative and End of Life Care
• Behavioral Health
• Care Transitions
• Medication Reconciliation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Must meet statutory requirements for all-condition potentially preventable hospital readmissions measure for SNFs.
• Must provide documentation sufficient to complete MUC list required data fields.
• Measures should be NQF endorsed, save where due consideration is given to endorsed measures of the same specified area or medical topic.
• May incorporate Medicare claims and/or alternative data sources will be considered dependent upon available infrastructure.

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

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

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

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

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

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

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

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

Index of Measures (by Program)

• Ambulatory surgery patients with appropriate method of hair removal (Public comments received:1; MUC ID: E0515)
  
  

• Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization (Public comments received:2; MUC ID: X3727)
  
  
• Timely Evaluation of High-Risk Individuals in the Emergency Department (No public comments received; MUC ID: X1234)
  
  

• IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Public comments received:8; MUC ID: S2633)
  
  

• Compliance with Ventilator Process Elements during LTCH stay (Public comments received:1; MUC ID: X3705)
  
  

• External Beam Radiotherapy for Bone Metastases (No public comments received; MUC ID: E1822)
  
  

• Adult Kidney Disease: Referral to Hospice (No public comments received; MUC ID: X3732)
  
  
• Evaluation or Interview for Risk of Opioid Misuse (No public comments received; MUC ID: X3774)
  
  
• In-hospital mortality following elective open repair of AAAs (No public comments received; MUC ID: E1523)
  
  

• Adult Kidney Disease: Referral to Hospice (Public comments received:1; MUC ID: X3732)
  
  
• Evaluation or Interview for Risk of Opioid Misuse (Public comments received:2; MUC ID: X3774)
  
  
• In-hospital mortality following elective open repair of AAAs (No public comments received; MUC ID: E1523)
  
  

• Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (Public comments received:1; MUC ID: S2510)
  
  

Full Comments (Listed by Measure)

• This measure focuses on a process of care that is associated with reduced rates of surgical site infection, and has been endorsed by NQF since 2007. Over the last seven years it has been used by thousands of ASCs participating in the ASC Quality Collaboration’s public reporting program, which posts aggregated quarterly results online. Our experience suggests the measure data is usable, and that data collection and reporting is not unduly burdensome. (Submitted by: ASC Quality Collaboration (ASC QC))
  
  

• Support pending NQF endorsement. Complications, readmissions and mortality after medical conditions or patient discharge may be reducible with application of currently available patient monitoring technologies in the acute care and home care setting. These patient monitoring technologies may permit “early warning” of complications and permit intervention before complications worsen to increase inpatient length of stay, cause unplanned readmission, or cause death. (Submitted by: AdvaMed)
  
  

• Restoring patient function is one of the fundamental purposes of inpatient rehabilitation hospitals and units. Unfortunately, the functional measures under consideration by the MAP are not ready for implementation at this time for a variety of reasons. As it pertains to this measure, it appears that the CARE tool is used to determine whether the patient should be excluded from this measure. At this time the CARE tool is not used by the industry for any purpose. In fact, an assessment tool known as the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) is in use for payment (and some quality) purposes. To expect IRH/Us to use one functional tool for payment purposes (the FIM tool on the IRF PAI) and a second tool for quality purposes (the CARE Tool) is duplicative and imposes an unnecessary burden and potential for error. We are also concerned that use of the CARE Tool will require a significant amount of training on the part of the industry. As a result, it would be inappropriate to adopt the use of the CARE Tool prematurely and for such a specific purpose. Additionally the numerator and denominator for the measure do not appear to make sense indicating that more patients discharged would lead to a lower measure score. Also, the measure needs risk adjustment to protect access for vulnerable populations. However, we do support the exclusion criteria for incomplete stays and stays of less than three days. As development of this measure moves forward we encourage the continued use of these exclusion criteria. (Submitted by: American Medical Rehabilitation Providers Association)
  
  
• We thank the Measure Applications Partnership (MAP) for this opportunity to provide feedback to guide the Post-Acute Care/Long-Term Care Workgroup as it evaluates the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (S2633) measure. UDSMR has carefully reviewed this measure and all related materials provided as part of the measure submission and consideration process. We have the following concerns related to the potential implementation of this measure: 1. First, we are highly concerned about the measure’s validity. The demonstration project in which the measure was developed used a cross-sectional study design that collected patient data on a single post-acute stay. There is no data (medical or functional) from the patient’s acute stay and no information on any subsequent acute or post-acute care utilization. This is problematic because aside from demonstrating the measure’s reliability (i.e., the stability and consistency of items), the study’s design cannot determine whether the measures actually predict anything, such as the likelihood of discharge to a community setting, resource utilization (including cost of care), the patient’s length of stay in post-acute care, the likelihood of readmission to acute care, or the appropriateness of inpatient readmission (functional gain). If the measure cannot be demonstrated to predict outcomes of interest, its value as a data collection tool is highly questionable, especially for inpatient rehabilitation facilities already heavily burdened by the administrative costs of data collection. A strong rationale with compelling supportive data is needed but has not yet been provided to the general public. 2. The risk-adjustment methodology appears to have been developed from a limited data set constructed as part of the PAC PRD project. In contrast to the IRF statistics reported in the March 2014 MedPAC report, the sample utilized in the development of this measure represents only 1% of all IRF Medicare cases and comes from just 3% of all IRFs. This brings into question the measure’s ability to be representative of the IRF population. Some of the risk-adjustment coefficients were produced from very small populations. (Several impairment groups have fewer than thirty cases.) The reliability of such a severity-adjustment methodology is highly questionable because classification and regression tree modeling, which was used for the analysis, requires hundreds or thousands of cases to be considered. We caution CMS and the Post-Acute Care/Long-Term Care Workgroup to carefully review the analyses, as proceeding with a risk-adjustment methodology that was developed from twenty or thirty patients with brain injury collected from two or three IRFs, for instance, could have serious implications for IRF providers and could negatively affect patients’ access to inpatient rehabilitation and quality of care. 3. Adding to the concern regarding the sample size used for the analyses, the data set used to develop the measure is now between four and six years old. As the aforementioned March 2014 MedPAC report shows, impairment populations admitted to an IRF have changed within the past two years. In the past, orthopedic patients were one of the most prevalent groups treated in inpatient rehabilitation. At present, the number of patients with an orthopedic condition has decreased substantially, having been replaced in part by patients with neurologic impairments. The data used in developing this measure does not account for this shift in patient distribution. Given these concerns about the applicability of this measure to the current IRF population, we question both its ability to add value to the IRF program measure set and its ability to improve patient outcomes. 4. We are concerned about the measure’s inclusion of functional items that are very similar to, but not analogous to, the FIM® items that are currently assessed as part of the IRF-PAI for payment purposes. (The IRF-PAI uses the eighteen-item FIM® instrument, which already measures both mobility and self-care.) Implementation of measure S2633 would require the collection of an additional seven functional items that utilize a rating scale and a data collection timeline that differ from those currently in place at IRFs. This would (1) increase the burden on the provider, (2) cause confusion for clinicians, and (3) compromise the value and utility of quality reporting and payment systems. The functional items currently used in the IRF-PAI are a collective data set that has been used to predict length of stay, costs, and payment. Even though the measure’s functional items border on duplicating the FIM® items, they are, as noted earlier, not analogous, and items from one instrument or measure cannot be switched with those in another without serious consequences. 5. As noted above, this measure utilized data from the PAC PRD project, which was tasked with identifying items (functional, medical, or otherwise) for utilization in a potential post-acute care standardized assessment instrument. The research on the measure does not provide evidence to suggest that the functional items within the proposed measure provide any additional value or predictability in regard to IRF outcomes. Additionally, because these items may be considered similar to or duplicative of FIM® items currently assessed in IRFs, we are concerned about both the burden of collecting and reporting data for this measure and the potential for affecting the IRF-PAI data currently utilized for payment as part of the IRF PPS. 6. We believe that the time required to assess patients on both the current functional items for payment (in the IRF-PAI) and the proposed functional items for “quality” will take away from time spent on actual patient care and could negatively affect patients’ outcomes. As a result, we believe that this measure would place upon IRFs an undue burden related to data collection and reporting for a measure that (1) is very similar to existing items already collected and (2) has not demonstrated any improvement, greater predictability of outcomes, or added value for patients or IRFs. In other words, how will the proposed measure improve patient outcomes over what is presently in place? Improvements in measuring or collecting data that has not previously been collected are warranted, but demonstrating the extent of improvement is equally necessary. Otherwise, the effect of adding measures may be the opposite of what is intended. Data may become unreliable or, as mentioned above, clinicians may spend more time completing paperwork and less time providing care and rehabilitation to their patients. UDSMR believes that any quality measures used in the inpatient rehabilitation setting must take into account the overriding goal of rehabilitation, which is to decrease the burden of care among individuals requiring rehabilitation, thereby allowing patients to return to a community setting. UDSMR urges CMS and the Post-Acute Care/Long-Term Care Workgroup to carefully consider the limitations inherent in the measures under consideration. (Submitted by: Uniform Data System for Medical Rehabilitation (UDSMR))
  
  
• We agree with CMS that the IRF QRP could be greatly enhanced by addressing IRF-specific core measure concepts and safety issues. The most fundamental core measure for IRFs should pertain to patients’ functional improvement and the ability to continue activities of daily living upon discharge back to their communities. The functional measures S2633, S2634, S2635, S2636 as proposed in the MUC list were developed as part of the Continuity Assessment Record and Evaluation (“CARE”) Tool. However, the inpatient rehabilitation facility (IRF) community feels strongly that the functional status measures as defined and reported through the UDSMR “FIM”® tool are stronger and more appropriate for IRFs. For more than two decades and data produced the FIM® are already reported to CMS. The FIM® tool is available to CMS free of charge and has been offered to NQF for perpetual use, royalty free. Many IRFs have built the FIM® tool directly into their record and payment systems and maintain a significant amount of historical data. By modifying or changing the core measures already in standard use by IRFs for patients’ functional improvement, even slightly, CMS would greatly exhaust clinician and hospital resources as they attempt to adapt to the special Medicare-only measures. The FIM® measure is also reported to CMS by IRFs as part of the IRF Patient Assessment Instrument (“IRF-PAI”) reporting process as required under applicable statutes and regulations governing the Inpatient Rehabilitation Facility Prospective Payment System (“IRF PPS”). It is also unclear whether the proposed functional measures will replace the FIM® measure entirely, or will be used alongside the FIM® measures, possibly as a mere quality indicator (in addition to the IRF-PAI). Using these proposed functional measures alongside FIM® would create two similar, but fundamentally different, functional rating scales. This would cause confusion among IRF practitioners and clinicians. Having two measures of function for each patient would be overly confusing and burdensome, and could easily confound patients who try to understand how to meet specific functional goals. The proposed CARE Tool functional measures are not as sensitive to differentiating patient functional level as FIM®. The CARE Tool item set and the proposed functional measures have only six levels of function, one level less than the existing FIM® functional measure. This one-level difference makes the proposed functional measures less differentiated among one another, and therefore less capable of expressing a patient’s precise functional status. As healthcare strives to be more patient centered, these proposed CARE Tool functional measures seem to shift the focus from the patient to the clinician by describing the amount of work the clinician must complete in order to perform the task. The unintended consequence of describing the burden of care from the clinician perspective, rather than from the patient/family perspective, could degrade the patient experience overall. Conversely, the FIM® measure approach of looking at the amount of work the patient must perform in order to progress through the FIM® levels shifts the focus closer to the patient’s individualized rehabilitation and therapy goals. The differences in the items scored to indicate a patient’s function do not support independence and/or a transition to home. For example, the FIM® bowel and bladder score measures the patient’s ability to manage their bladder and the number of times an accident occurs. An accident is defined as “the act of wetting linen or clothing with urine, including bedpan and urinal spills.” This aspect of the FIM® measure supports the general principle that a patient’s independence can be achieved by demonstrating the functional capacity to prevent incontinence (the loss of bladder control) from wetting clothes or linen. Both the burden of care and the outcome of that care remain with the patient. However, the CARE Item Set measures incontinence regardless of whether or not the patient is able to prevent soiling linen or clothing. This fundamental change in philosophy of what constitutes independence has the potential to change the practice of rehabilitation nursing, as the focus will no longer be on assisting patients in managing their bladder issues. (Submitted by: Federation of American Hospitals)
  
  
• We agree with CMS that the IRF QRP could be greatly enhanced by addressing IRF-specific core measure concepts and safety issues. The most fundamental core measure for IRFs should pertain to patients’ functional improvement and the ability to continue activities of daily living upon discharge back to their communities. The functional measures proposed as MUC were developed as part of the Continuity Assessment Record and Evaluation (“CARE”) Tool. However, the UDSMR “FIM”® tool has been in use by all IRFs for over two decades and data produced by it are already reported to CMS. The FIM® tool is available to CMS free of charge and has been offered to NQF for perpetual use, royalty free. Many IRFs have built the FIM® tool directly into their record and payment systems and maintain a significant amount of historical data. By modifying or changing the core measures already in standard use by IRFs for patients’ functional improvement, even slightly, CMS would greatly exhaust clinician and hospital resources as they attempt to adapt to the special Medicare-only measures. STRENGTH OF EXISTING FUNCTIONAL MEASURE Approving these functional measures for use in an IRF undercuts the existing measures that is already in use by all IRFs. The FIM® functional measure has been validated, accepted, and used by clinicians and medical rehabilitation practitioners within all of America’s rehabilitation hospitals and hospital-based inpatient rehabilitation units (collectively known as inpatient rehabilitation facilities, or “IRFs”) for over two decades. The FIM® measure is also reported to CMS by IRFs as part of the IRF Patient Assessment Instrument (“IRF-PAI”) reporting process as required under applicable statutes and regulations governing the Inpatient Rehabilitation Facility Prospective Payment System (“IRF PPS”). In addition, the FIM® functional measure is available for use on a royalty-free basis for the purpose of quality reporting and along with other FIM® derivatives can be used across all post-acute care and long-term care (“PAC/LTCH”) settings. Modifying the core measure already in standard use by IRFs and other rehabilitation providers for functional improvement would greatly exhaust clinician and hospital resources, particularly if the new functional measure was not substantially improved over the existing measure. It is also unclear whether the proposed functional measures will replace the FIM® measure entirely, or will be used alongside the FIM® measures, possibly as a mere quality indicator (in addition to the IRF-PAI). Using these proposed functional measures alongside FIM® would create two similar, but fundamentally different, functional rating scales. This would cause confusion among IRF practitioners and clinicians. Having two measures of function for each patient would be overly confusing and burdensome, and could easily confound patients who try to understand how to meet specific functional goals. The proposed functional measures are not as sensitive to differing patient functional level as FIM®. The CARE Tool item set and the proposed functional measures have only six levels of function, one level less than the existing FIM® functional measure. This one-level difference makes the proposed functional measures less differentiated among one another, and therefore less capable of expressing a patient’s precise functional status. As healthcare strives to be more patient centered, the proposed functional measures seem to shift the focus from the patient to the clinician by describing the amount of work the clinician must complete in order to perform the task. The unintended consequence of describing the burden of care from the clinician perspective, rather than from the patient/family perspective, could degrade the patient experience overall. Conversely, the FIM® measure approach of looking at the amount of work the patient must perform in order to progress through the FIM® levels shifts the focus closer to the patient’s individualized rehabilitation and therapy goals. The MUC functional measures (CARE Item Set) only have 6 levels of function, which is one level less than the existing FIM® functional measure. This makes the CARE Item Set less differentiated, which would make it a less sensitive tool compared to the FIM® functional measure. When selecting a quality measure, the more sensitive the tool – the more descriptive and accurate the quality measure will be. Additionally, as healthcare strives to be more patient centered, the CARE Item Set seems to shift the focus from the patient to the clinician by describing the amount of work the helper must do to perform the task. The unintended consequence of describing the burden of care from the clinician perspective, rather than from the patient/family perspective, could degrade the patient experience. Conversely, the FIM® measure approach of looking at the amount of work the patient performs moves the focus closer to the patient’s individual rehabilitation and therapy goals. The differences in the items scored to indicate a patient’s function do not support independence and/or a transition to home. For example, the FIM® bowel and bladder score measures the patient’s ability to manage their bladder and the number of times an accident occurs. An accident is defined as “the act of wetting linen or clothing with urine, including bedpan and urinal spills.” This aspect of the FIM® measure supports the general principle that a patient’s independence can be achieved by demonstrating the functional capacity to prevent incontinence (the loss of bladder control) from wetting clothes or linen. Both the burden of care, and the outcome of that care, remain with the patient. By contrast, the CARE Item Set measure measures incontinence regardless of whether or not the patient is able to prevent soiling linen or clothing. This fundamental change in philosophy of what constitutes independence has the potential to change the practice of rehabilitation nursing, as the focus will no longer be on assisting patients in managing their bladder issues. TECHNICAL ISSUE The two measures related to mean change (self-care and mobility) do not appropriately calculate a mean. The numerators “mean change in mobility/self-care” over a denominator of “patients discharged” seems to inappropriately divide the average change of the functional measure by the number of patients discharged by the facility. This would cause discharge numbers to affect the mean functional change in a non-relevant way. REGARDING THE FUNCTIONAL MEASURES UNDER CONSIDERATION -We respectfully urge that careful consideration be given to the strength of the FIM® measure as demonstrated by its clinical validity and broad acceptability within and throughout the entire rehabilitation hospital sector. -FIM® elements are reflective of a core principle embedded within the National Quality Strategy, namely, ensuring that patients receive clear information that can enable them to actively participate in their own care. Any measures or instrument designed to examine patients’ functional outcomes should place ample weight on the patient and their individual achievements; too much weight assigned to the role of caregivers or clinicians could discourage such active participation. -Simultaneous application of FIM® and new functional measures would be overly burdensome and duplicative, and could result in conflicting outcome results. (Submitted by: HealthSouth Corporation)
  
  
• We agree in principal with the concept of using funcitonal outcome measures as quality measures for inpatient rehabilitation hospitals. However, there are already functional measures in use by IRFs that have been validated and accepted by the industry and CMS that would be less burdensome for hospitals . (Submitted by: Healthsouth)
  
  
• I'm unsure why this and the other functional outcome measures are being considered as quality measures for Inpatient Rehabiltiation, when the industry already has a standard, industry-accepted tool (FIM). It would be a significant burden to retrain dozens of employees at each hospital on a similar (less sensitive) measure for no positive benefit. If a better quality tool emerges to warrant such a significant change to functional measure reporting in IRFs, I would support such a move - but this seems like it's just changing a measure to change a measure. Even these items are standardized for different post-acute settings, they are all slightly unique - which means they are not comparable. Additionally, IRFs have decades of FIM data to track and trend. Changing to a new tool for no demonstrable reason means losing millions of valuable records. Also, the calculation of the measure itself (mean change in function/discharged patients) seems like a mistake. This would divide the mean change over the number of patients. Which means two hospitals with the same mean change could have their average affected by number of patients admitted. This seems like an error. (Submitted by: HealthSouth Corporation)
  
  
• These comments pertain equally to S2633 - S2366, because all four of these measures embrace the assumption that an entirely new methodology for measuring patients' functional outcomes should be adopted, despite the fact that clinicians in the field of rehabilitation have been consistently and successfully using a well-validated functional measurement tool for decades. This tool, known as FIM, has been the basis for both academic research and clinical documentation. Having consistent, longitudinal data is of immense importance in the field of quality improvement. One reason the FIM data is such a gold mine is that CMS has required the submission of admission and discharge FIM data on every single patient for such a long time. To eradicate the value of such a rich data base by switching to a new measurement tool is a huge price to pay for a change. Obviously, such a change would have to offer incredibly important advantages to overcome this loss. Frankly, CMS has not, to my knowledge, ever described specifically what advantages it feels the CARE Tool's functional measures offer over the well-researched FIM measures. Let me urge the MAP, before acting to endorse any of these 4 functional measures that incorporate CARE Tool metrics, to demand some convincing evidence that FIM measures have some significant deficiencies that are resolved by the CARE functional measures. It would be reasonable to expect CMS to provide a chart that specifically identifies such "problems" and "solutions" before the MAP takes the entire rehabilitation industry down the road of (1) increased expense to retrain tens of thousands of clinicians in the entire rehabilitation sector, (2) losing decades of comparative data, (3) risking deterioration in the quality of the data because of user confusion (4) requiring total rebuilding of rehabilitation-specific electronic medical records which have all embedded the FIM tool. (It may be worth noting that EMR development in rehabilitation hospitals has received no federal support since we are not eligible for HITECH funding.) At one point, CMS may have pursued the creation of new functional measures out of a belief that the FIM measures were proprietary and unavailable; but that turned out not to be accurate. CMS also was looking for a tool that could be used across settings; but the FIM tool could be used across settings just as well as CARE's functional measures. And the current measures under consideration are not proposed to be incorporated into requirements for SNFs. To pursue a switch from FIM to CARE, with all of the associated costs, without some certainty of dramatic benefits to be achieved, works in opposition to MAP's mission. Functional improvement ---- and the measurement of it --- lies at the foundation of rehabilitation medicine. Our field has been a leader in outcome measurement, having developed and used the FIM for decades. CMS's Quality Reporting Program should build on such successes, not dismantle them. Sincerely, Dexanne B. Clohan, MD (Submitted by: HealthSouth Corporation)
  
  
• My family members have been patients in our rehab hospital and I'm concerned that a change from a good functional measurement system to another system could decrease the quality of care provided to patients while staff learn a whole new system. Plus historical data from several decades could be lost. In addition, as an employee, I am concerned about the tremendous cost in dollars and employee time to learn a brand new system as well as the cost to modify the EMR built around a current functional measure system. (Submitted by: HealthSouth Corporation)
  
  

• Support pending NQF endorsement. Currently available modes of invasive mechanical ventilation encourage patient spontaneous breathing and promote liberation from mechanical ventilation, contributing to successful spontaneous breathing trials. (Submitted by: AdvaMed)
  
  

• The ACEP Quality and Performance Committee appreciates the opportunity to comment on the Hospital 30-day all cause unplanned risk-standardized days in acute care following hospitalization measures. Intensity and cost of ED visits and type 1 observation is much less than for admission, in fact ED visits cost Medicare approximately one tenth of an inpatient admission (Morganti 2013). These returns to acute outpatient care should be weighted differently than readmissions given that emergency care may be the only care available for those with acute illness or acute exacerbations of chronic conditions for 128 out of 168 hours per week in many communities. There has not been a chart review or validation of these metrics, which would indicate that these returns to care were not urgent or emergent. In fact the most recent data from the CDC NHAMCS indicate that 92% of all visits to the ED are urgent or emergent across all payers, and that number is even higher for the Medicare population (CDC 2014). Recent studies have categorized observation care into four settings based on the use of a dedicated observation unit and the use of observation protocols (Ross 2013). A type 1setting is a protocol driven observation unit, type 2- an observation unit (without the use of protocols), type 3 - a bed anywhere in the hospital with the use of protocols, and type 4-is discretionary care anywhere in a hospital. Nine prospective randomized studies, the highest standard for clinical research, have all shown better clinical and economic outcomes when care is rendered in a type 1 setting (Ross 2012). A recent analysis of national claims data compared observation care in a type 1 setting with traditional settings using regional and national claims data. It found that type 1 settings offered 38% shorter stays, 44% lower admit rates, with estimated national cost savings of $950 million per year for observation patients (Baugh 2012). In fact, the ED is likely the most appropriate and beneficial setting of care for these patients in addition to being the only setting of care outside regular business hours. There is no compelling scientific evidence for this measure, as DHHS’s own research has demonstrated that national readmission rates, which hovered around 19% between 2007 and 2011, had dropped to approximately 17.5% by 2013, and that the decrease resulted from actual changes in care and not greater use of observation units or emergency department care (DHHS 2014, Cassel 2014). Baugh, C.W., A. K.Venkatesh, J. A. Hilton, P. A. Samuel, J. D. Schuur, and J. S. Bohan. 2012. “Making Greater Use of Dedicated Hospital Observation Units for Many Short-Stay Patients Could Save $3.1 Billion a Year.” Health Affairs 31 (10): 2314–23. Christine K. Cassel, M.D., Patrick H. Conway, M.D., Suzanne F. Delbanco, Ph.D., Ashish K. Jha, M.D., M.P.H., Robert S. Saunders, Ph.D., and Thomas H. Lee, M.D. Getting More Performance from Performance Measurement. N Engl J Med 2014; 371:2145-2147 Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey Emergency Department 2011 Factsheet. Accessed on: November 18, 2014. Accessed at:http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf Department of Health and Human Services. New HHS data shows major strides made in patient safety, leading to improved care and savings. May 7, 2014 (http://innovation.cms.gov/Files/reports/patient-safety-results.pdf) Morganti KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, Vesely JV, Okeke EN, Kellermann AL. The Evolving Role of Emergency Departments in the United States. RAND Health 2013. Accessed on August 26, 2013. Accessed at: http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf Ross MA, Aurora T, Graff L, Suri P, O’Malley R, Ojo A, Bohan S, Clark C. State of the Art: Emergency Department Observation Units. Critical Pathways in Cardiology 2012;11: 128–138 Ross MA, Hockenberry JM, Mutter R, Wheatley M, Pitts S. Protocol-Driven Emergency Department Observation Units Offer Savings, Shorter Stays, And Reduced Admissions. Health Affairs. Pub pending, 2013 Dec; 32(12):2149-2156 (Submitted by: American College of Emergency Physicians Quality & Performance Committee)
  
  
• Support pending NQF endorsement. Complications, readmissions and mortality after medical conditions or patient discharge may be reducible with application of currently available patient monitoring technologies in the acute care and home care setting. These patient monitoring technologies may permit “early warning” of complications and permit intervention before complications worsen to increase inpatient length of stay, cause unplanned readmission, or cause death. (Submitted by: AdvaMed)
  
  

• ASN supports this in concept, although believes this measure must clearly define ‘withdrawal’ as well as define how inpatient (hospital level) vs outpatient and subacute facilities are accounted for in the denominator and numerator, respectively. We would be pleased to work with CMS to develop precise definitions for use in a measure like this. (Submitted by: American Society of Nephrology (ASN))
  
  

• The AAN strongly encourages the MAP to consider recommendation of this measure for inclusion in CMS programs. (Submitted by: American Academy of Neurology)
  
  
• ASN supports this in concept, although believes that this should apply to the prescribing individual/practice/setting rather than to every setting in which the patient is seen. (Submitted by: American Society of Nephrology (ASN))
  
  

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.

Remote Participation Instructions:

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

• Dial ### for workgroup members or ### for public participants ; use conference ID code for Day 1: ###### or Day 2: ###### to access the audio platform.