NQF
Version Number: 13.1
Meeting
Date: December 24, 2015
Measure Applications Partnership
Example Discussion Guide
DEMO--NOT ACTUAL MAP MEETING MATERIALS
Key Tips
- Use the back and forward buttons on your browser
to navigate (such as returning to your place after
you've clicked a link).
- Please don't print. The paper version will be very
long and difficult to navigate.
- The discussion guide will be updated as we get more
information, such as public comments.
- Further
instructions and help
- Joining
remotely?
This is an example discussion
guide to demonstrate how the tool works. The measures are
drawn from last year's MUC list to provide a sense of what
information will be available. These are not actual meeting
materials for measure review. |
Agenda
Agenda Synopsis
Full Agenda
9:00 am |
Welcome, Introductions, and Review of
Meeting Objectives |
|
|
9:15 am |
Approach to Preliminary Analysis |
|
Reva Winkler, NQF
|
9:30 am |
Consent Calendar: Clinician |
|
Reva Winkler, NQF |
|
- In-hospital mortality following elective open
repair of AAAs (MUC ID: E1523)
- Description: Percentage of asymptomatic
patients undergoing open repair of abdominal
aortic aneurysms (AAA) who die while in hospital.
This measure is proposed for both hospitals and
individual providers. (Measure
Specifications; Summary
of Endorsement Review)
- Programs under consideration: Physician
Quality Reporting System (PQRS)
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Support
- In-hospital mortality following elective open
repair of AAAs (MUC ID: E1523)
- Description: Percentage of asymptomatic
patients undergoing open repair of abdominal
aortic aneurysms (AAA) who die while in hospital.
This measure is proposed for both hospitals and
individual providers. (Measure
Specifications; Summary
of Endorsement Review)
- Programs under consideration: Physician
Compare
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result:
Public-facing clinician web page
- Evaluation or Interview for Risk of Opioid Misuse
(MUC ID: X3774)
- Description: All patients 18 and older
prescribed opiates for longer than six weeks
duration evaluated for risk of opioid misuse using
a brief validated instrument (e.g. Opioid Risk
Tool, SOAAP-R) or patient interview documented at
least once during COT in the medical record. (Measure
Specifications)
- Programs under consideration: Physician
Quality Reporting System (PQRS)
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Conditional
support
- Evaluation or Interview for Risk of Opioid Misuse
(MUC ID: X3774)
- Description: All patients 18 and older
prescribed opiates for longer than six weeks
duration evaluated for risk of opioid misuse using
a brief validated instrument (e.g. Opioid Risk
Tool, SOAAP-R) or patient interview documented at
least once during COT in the medical record. (Measure
Specifications)
- Programs under consideration: Physician
Compare
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result:
Spreadsheet
- Adult Kidney Disease: Referral to Hospice
(MUC ID: X3732)
- Description: Percentage of patients aged
18 years and older with a diagnosis of ESRD who
withdraw from hemodialysis or peritoneal dialysis
who are referred to hospice care (Measure
Specifications)
- Programs under consideration: Physician
Quality Reporting System (PQRS)
- Public comments received: 1
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Encourage
continued development
- Adult Kidney Disease: Referral to Hospice
(MUC ID: X3732)
- Description: Percentage of patients aged
18 years and older with a diagnosis of ESRD who
withdraw from hemodialysis or peritoneal dialysis
who are referred to hospice care (Measure
Specifications)
- Programs under consideration: Physician
Compare
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result:
Public-facing clinician web page
|
10:30 am |
Consent Calendar: Hospital |
|
Erin O'Rourke, NQF |
|
- External Beam Radiotherapy for Bone Metastases
(MUC ID: E1822)
- 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.
(Measure
Specifications; Summary
of Endorsement Review)
- Programs under consideration: Hospital
Outpatient Quality Reporting Program
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Support
- Hospital 30-day, all-cause, unplanned
risk-standardized days in acute care following
pneumonia hospitalization (MUC ID: X3727)
- 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. (Measure
Specifications)
- Programs under consideration: Hospital
Inpatient Quality Reporting
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Conditional
support
- Ambulatory surgery patients with appropriate
method of hair removal (MUC ID: E0515)
- Description: Percentage of ASC admissions
with appropriate surgical site hair removal. (Measure
Specifications; Summary
of Endorsement Review)
- Programs under consideration: Ambulatory
Surgical Center Quality Reporting Program
- Public comments received: 1
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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%
- Preliminary analysis result: Do not
support
- Timely Evaluation of High-Risk Individuals in the
Emergency Department (MUC ID: X1234)
- Description: Median time from emergency
department (ED) arrival to provider evaluation for
individuals triaged at the two highest levels
based on a five-level triage system (e.g., triaged
as “immediate” or “emergent”). (Measure
Specifications)
- Programs under consideration: Hospital
Inpatient Quality Reporting
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Encourage
continued development
|
11:30 am |
Lunch |
|
|
12:00 pm |
Consent Calendar: PAC/LTC |
|
Kathryn Streeter, NQF |
|
- Skilled Nursing Facility All-Cause 30 Day Post
Discharge Readmission Measure (MUC ID: S2510)
- 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. (Measure
Specifications)
- Programs under consideration: Skilled
Nursing Facility Value-Based Purchasing
Program
- Public comments received: 1
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Support
- IRF Functional Outcome Measure: Change in
Self-Care Score for Medical Rehabilitation Patients
(MUC ID: S2633)
- Description: This measure estimates the
average risk-adjusted mean change in self-care
function between admission and discharge for
patients discharged from IRFs. (Measure
Specifications)
- Programs under consideration: Inpatient
Rehabilitation Facility Quality Reporting
Program
- Public comments received: 8
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Conditional
support
- Compliance with Ventilator Process Elements
during LTCH stay (MUC ID: X3705)
- 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. (Measure
Specifications)
- Programs under consideration: Long-Term
Care Hospital Quality Reporting Program
- Public comments received: 1
- Preliminary analysis summary (Full
Preliminary Analysis)
- 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.
- Preliminary analysis result: Encourage
continued development
|
1:00 pm |
Next Steps |
|
|
1:15 pm |
Adjourn |
|
|
Appendix A: Measure Information
Measure Index
Ambulatory Surgical Center Quality Reporting Program
Hospital Inpatient Quality Reporting
Inpatient Rehabilitation Facility Quality Reporting Program
Long-Term Care Hospital Quality Reporting Program
Hospital Outpatient Quality Reporting Program
Physician Compare
Physician Quality Reporting System (PQRS)
Skilled Nursing Facility Value-Based Purchasing Program
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.
Appendix B: Program Summaries
The material in this
appendix was drawn from the CMS
Program Specific Measure Priorities and Needs document, which
accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the most
recent measures in different federal programs.
Program Index
Full Program Summaries
The material
for this program was drawn from the program summary developed for last
year's MAP pre-rulemaking cycle. This program will be replaced by the
Merit-Based Incentive Payment System (MIPS) per recent
legislation.
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
The material for this program was drawn directly
from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
Program History and Structure: Section 10331 of the 2010
Patient Protection & Affordable Care Act (ACA) requires CMS to
establish the Physician Compare website to publicly report physician
performance data. The goal of the Physician Compare website is to provide
reliable information for consumers to encourage informed health care
decisions; and to create explicit incentives for physicians to maximize
performance. To meet the statutory mandate, CMS repurposed the
Medicare.gov Healthcare Provider Directory into Physician Compare. On
December 30, 2010, CMS officially launched the Physician Compare website
using the Medicare Provider Enrollment, Chain, and Ownership System
(PECOS) as its underlying data source. Based on stakeholder feedback and
understanding the Affordable Care Act (ACA) requirements for the site,
CMS redesigned Physician Compare in June 2013. Since that time, CMS has
been working continually to enhance the site and its functionality,
improve the information available, and include more and increasingly
useful information about the physicians and other health care
professionals who are on the website.
The 2012 Physician
Fee Schedule final rule indicated that the first measures available for
public reporting on Physician Compare would be a sub-set of the 2012
Physician Quality Reporting System (PQRS) Group Practice Reporting Option
(GPRO) measures collected via the Web Interface. CMS publicly reported
this first set of measure data in February 2014 for the 66 group
practices and 141 ACOs. In December 2014, the next phase of public
reporting was accomplished with the posting of a sub-set of the 2013 PQRS
GPRO Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) measures
collected via the Web Interface for 139 group practices and 214 Shared
Savings Program and 23 Pioneer ACOS. In addition, CAHPS for ACO summary
survey measures were added to Physician Compare. The following quality
measures were publicly reported in December 2014:
2013
PQRS GPRO and ACO measures
- A sub-set of 3 DM and 1 CAD Web Interface measures.
- Diabetes: High Blood Pressure Control
- Diabetes: Hemoglobin A1c Control (<8%)
- Diabetes: Daily Aspirin or Antiplatelet Medication Use for
Patients with Diabetes and Ischemic Vascular Disease
- Coronary Artery Disease (CAD): ACE-I/ARB Therapy – Diabetes
or LVSD
2013 CAHPS for ACOs measures
- 4 CAHPS for ACOs summary survey measures.
- Getting timely care, appointments, and information
- How well providers Communicate
- Patient’s Rating of Provider
- Health Promotion & Education
For 2014 data, all
PQRS GPRO measures collected via the Web Interface, as well as a sub-set of
measures reported via registry and EHR are available for public reporting
on Physician Compare. All measures reported by Shared Savings Program and
Pioneer ACOs are also available for public reporting. CMS will continue to
publicly report 2014 CAHPS for ACOs and will publish the first set of
CAHPS for PQRS measures for groups of 100 or more EPs who participate in
PQRS GPRO and for group practices of 25-99 EPs reporting via a certified
CAHPS vendor. In addition, twenty individual measures reported by EPs under
the 2014 PQRS via claims, EHR, or registry are available for public
reporting. All 2014 data are targeted for publication in late 2015.
For 2015 data, at the group practice level, all 2015 PQRS GPRO
measures reported via the Web Interface, registry, or EHR are available for
public reporting. In addition, the 12 summary survey 2015 CAHPS for PQRS
and CAHPS for ACO measures are available for public reporting for group
practices of 2 or more EPs and ACOs reporting via a CMS-approved certified
survey vendor. At the individual EP level, all 2015 PQRS measures reported
via registry, EHR, or claims are available for public reporting. In
addition, individual EP-level 2015 Qualified Clinical Data Registry (QCDR)
measures, which include PQRS and non-PQRS data, will be available for
public reporting on Physician Compare in late 2016.
Current Program Measure Information: Table 1 below provides the
number of quality measures under each domain of measurement from the
National Quality Strategy (NQS) priorities that were finalized in the
2012, 2013, 2014 and 2015 PFS final rules as available for public
reporting. Only those measures that are comparable, valid, reliable, and
suitable for public reporting will be publicly reported on Physician
Compare (see “Measure Requirements” below).
Table 1: Quality
Measures Finalized for Public Reporting by the 2012, 2013, 2014, &
2015 PFS Final Rules
NQS Priority
Domains
|
Number of
Measures Finalized for Potential Reporting on Physician
Compare
|
2012 PFS Final
Rule
|
2013 PFS Final
Rule
|
2014 PFS Final
Rule
|
2015 PFS Final
Rule
|
Groups
|
ACOs
|
Groups
|
ACOs
|
EPs
|
Groups
|
ACOs
|
EPs
|
Groups
|
ACOs
|
Effective Clinical Care
|
27
|
20
|
20
|
20
|
13
|
14
|
14
|
110
|
138
|
8
|
Patient Safety
|
1
|
1
|
1
|
1
|
2
|
2
|
2
|
26
|
34
|
2
|
Communication/Care Coordination
|
1
|
1
|
1
|
1
|
0
|
0
|
|
29
|
37
|
0
|
Community/Population Health
|
0
|
0
|
0
|
0
|
5
|
5
|
5
|
14
|
15
|
5
|
Efficiency and Cost Reduction
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
15
|
16
|
0
|
Person and Caregiver Centered Experience and
Outcomes
|
0
|
0
|
25
|
35
|
0
|
12
|
12
|
12
|
14
|
12
|
High Priority Domains for Future Measure Consideration: As we
move more toward expanded public reporting, it is critical to include
consumer-friendly measures. This means that measure development needs to
focus on creating measures that look at the types of information
consumers need to know to make informed health care decisions. PQRS was
originally a pay-for-reporting program without explicit intent to
publicly report quality measures. However, starting with 2015 data, all
PQRS measures are available for public reporting on Physician Compare.
Based on this expansion of public reporting and the changing use of
PQRS measures, it is critical to consider public reporting and the
consumer perspective during measure development. CMS identified the key
areas to consider when developing consumer-friendly measures.
- Outcome measures
- Composite measures
- Risk adjusted measures
Consumer testing has also shown that
users prefer outcome measures over process measures. In order for quality
measures to be meaningful to consumers, they must resonate with consumers.
We often hear that consumers do not think process measures are useful.
They want to understand if patients like them better or if a procedure was
successful. This is the information that will help them make informed
decisions.
Composite measures can help consumers accurately
interpret measures in a way that is meaningful to them while also removing
the burden of interpretation from them. Composite measures help make
data more digestible. It is much easier for a consumer to understand that a
doctor is good at diabetes care, for instance, than it is to understand why
it is important for a doctor to perform well across a series of technical
measures about glucose levels and treatment best practices. Similarly, risk
adjustment can ensure that consumers are more accurately comparing health
care professionals and group practices.
Consumers can provide
valuable feedback when engaged early in the measure development process.
They can determine if measures are understandable and useful in decision
making. We understand that all measures are not intended for public
reporting. However, the continued growth of public reporting makes the
consumer perspective increasingly important. Moving towards more
consumer-friendly measures, specifically outcome measures, composite
measures, and risk-adjusted measures, will be instrumental toward achieving
Physician Compare’s goal, as defined by the Affordable Care Act, of
providing consumers useful quality data to inform health care
decisions.
Measure Requirements: Although CMS has finalized the quality
measures listed in Table 1 for public reporting, not all of these quality
measures may ultimately be suitable for public reporting. Only
comparable, valid, reliable, and accurate data will be publicly reported.
For example, the performance results for certain measures may not be
statistically reliable if the total number of patients reported on is
low. Hence, to select a sub-set of quality measures finalized for public
reporting, CMS will need to analyze the actual measure performance
results collected for each program year. At minimum, any quality
measures selected for public reporting must meet the following
criteria:
- As statutorily mandated, quality measures must be statistically
valid and reliable, and risk adjustment should be considered for
outcome measures as appropriate.
- They must be readily comprehensible to users so that users can
leverage the performance information to inform their health care
decisions.
- They should enable users to make meaningful and valid comparisons
of performance results across health care professionals and group
practices by having the following properties:
- There should be sufficient variation in the performance
rates, since comparisons would be difficult if the majority of
providers are clustered at one or two performance rates.
- There should be room for improvement in the measure
performance.
- There should be a sufficient number of cases in the measure
denominator, since performance rates that are based only on a
handful of cases may result in unreliable rates and make
statistically valid comparisons difficult.
- There should be a sufficient number of health care
professionals or group practices in each peer group
comparison.
In addition, CMS will not publish any measures
that are in their first year and only those measures that prove to resonate
with consumers and are deemed to be relevant to consumers will be
included on the profile pages of the website. All other comparable, valid,
reliable, and accurate measures would be included in a publicly available
downloadable database, similar to the databases currently available on
data.medicare.gov.
The material for
this program was drawn directly from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- Patient and Family Engagement:
- Measures that foster the engagement of patients and families
as partners in their care.
- Best Practices of Healthy Living:
- Measures that promote best practices to enable healthy
living.
- Making Care Affordable:
- 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:
- Measure must adhere to CMS statutory requirements.
- 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)
- 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
- Measure must be claims-based or an electronically specified
clinical quality measure (eCQM).
- A Measure Authoring Tool (MAT) number must be provided for
all eCQMs, created in the HQMF format
- 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
- eCQMs must have successfully passed feasibility testing
- Measure may not require reporting to a proprietary registry.
- 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.
- Measure must be fully developed, tested, and validated in the
acute inpatient setting.
- 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.
- Measure must promote alignment across HHS and CMS programs.
- Measure steward will provide CMS with technical assistance and
clarifications on the measure as needed.
The
material for this program was drawn directly from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- Making Care Safer:
- Measures that address processes and outcomes designed to
reduce risk in the delivery of health care, e.g., emergency
department overcrowding and wait times.
- Best Practices of Healthy Living:
- Measures that focus on primary prevention of disease or
general screening for early detection of disease unrelated to a
current or prior condition.
- Patient and Family Engagement:
- Measures that address engaging both the person and their
family in their care.
- Measures that address cultural sensitivity, patient
decision-making support or care that reflects patient
preferences.
- Communication/Care Coordination:
- Measures to embed best practices to manage transitions across
practice settings.
- Measures to enable effective health care system
navigation.
- 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:
- Measure must adhere to CMS statutory requirements.
- 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
- 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
- Measure must address a NQS priority/CMS strategy goal, with
preference for measures addressing the high priority domains for
future measure consideration.
- 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.
- Measure must be fully developed, tested, and validated in the
hospital outpatient setting.
- Measure must promote alignment across HHS and CMS programs.
- Feasibility of Implementation: An evaluation of feasibility is
based on factors including, but not limited to
- The level of burden associated with validating measure data,
both for CMS and for the end user.
- Whether the identified CMS system for data collection is
prepared to accommodate the proposed measure(s) and timeline for
collection.
- The availability and practicability of measure
specifications, e.g., measure specifications in the public
domain.
- The level of burden the data collection system or methodology
poses for an end user.
- Measure steward will provide CMS with technical assistance and
clarifications on the measure as needed.
The
material for this program was drawn directly from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- Making Care Safer
- Measures of infection rates
- Person and Family Engagement
- Measures that improve experience of care for patients,
caregivers, and families.
- Measures to promote patient self-management.
- Best Practice of Healthy Living
- Measures to increase appropriate use of screening and
prevention services.
- Measures which will improve the quality of care for patients
with multiple chronic conditions.
- Measures to improve behavioral health access and quality of
care.
- Effective Prevention and Treatment
- Surgical outcome measures
- Communication/Care Coordination
- Measures to embed best practice to manage transitions across
practice settings.
- Measures to enable effective health care system
navigation.
- 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:
- Measure must adhere to CMS statutory requirements.
- 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
- 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
- Measure must address a NQS priority/CMS strategy goal, with
preference for measures addressing the high priority domains for
future measure consideration.
- 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.
- Measure must be field tested for the ASC clinical setting.
- Measure that is clinically useful.
- Reporting of measure limits data collection and submission burden
since many ASCs are small facilities with limited staffing.
- Measure must supply sufficient case numbers for differentiation
of ASC performance.
- Measure must promote alignment across HHS and CMS programs.
- Measure steward will provide CMS with technical assistance and
clarifications on the measure as needed.
The material for this program was drawn directly
from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- 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.
The material for this program was drawn directly
from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
The material for this program was drawn directly
from the CMS
Program Specific Measure Priorities and Needs document,
which accompanied the 2015 MUC list, and the CMS
Measure Inventory,which is regularly updated to include the
most recent measures in different federal programs.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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)
All measures are included in the
index, even if there were not any public comments about that measure for
that program.
Ambulatory Surgical Center Quality Reporting Program
Hospital Inpatient Quality Reporting
Inpatient Rehabilitation Facility Quality Reporting Program
Long-Term Care Hospital Quality Reporting Program
Hospital Outpatient Quality Reporting Program
- External Beam Radiotherapy for Bone Metastases (No public
comments received; MUC ID: E1822)
Physician Compare
- 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)
Physician Quality Reporting System (PQRS)
Skilled Nursing Facility Value-Based Purchasing Program
Full Comments (Listed by Measure)
(Program: Ambulatory Surgical Center
Quality Reporting Program; MUC ID: E0515) |
- 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))
(Program: Skilled Nursing
Facility Value-Based Purchasing Program; MUC ID: S2510)
|
- 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)
(Program: Inpatient
Rehabilitation Facility Quality Reporting Program; MUC ID:
S2633) |
- 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)
(Program: Long-Term Care Hospital Quality
Reporting Program; MUC ID: X3705) |
- Support pending NQF endorsement. Currently available modes of
invasive mechanical ventilation encourage patient spontaneous
breathing and promote liberation from mechanical ventilation,
contributing to successful spontaneous breathing trials. (Submitted
by: AdvaMed)
(Program: Hospital Inpatient Quality Reporting; MUC ID:
X3727) |
- 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)
(Program:
Physician Quality Reporting System (PQRS) ; MUC ID: X3732)
|
- 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))
(Program: Physician Quality Reporting System (PQRS) ; MUC ID:
X3774) |
- 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))
Appendix D: Instructions and Help
If you have any
problems navigating the discussion guide, please contact us at: measureapplications@qualityforum.org
Navigating the Discussion Guide
- How do I get back to the section I was just looking at?
The easiest way is to use the back button on your browser. Other
options are using your backspace button (which works for many
browsers on laptops), or using the permanent links at the upper right
hand corner of the discussion guide. But the back button is the best
choice in most situations.
- Can I print the discussion guide out?
You can, but we
don't recommend it. Besides using a lot of paper (probably a couple
hundred pages at least), you'll lose all the links that allow you to
move around the document. For instance, if you're scrolling through
the agenda and want to see more information about a particular
measure, the electronic format will allow you to click a link, read
more, and then bo back. If you're on paper, there will be a lot of
flipping through paper.
- If I can't print this out, how can I read it on the
plane?
We will send you a pdf/Adobe Acrobat file a few days
before the meeting, which will hopefully be useful when you're
reviewing the discussion guide as you travel to Washington,
DC.
- How do I know that I'm looking at the most recent
version?
At the top left corner of the discussion guide is a
version number. At the beginning of the in person meetings, the NQF
staff will ask everyone to load the most recent discussion
guide version and will check that everyone has the same version
loaded.
- What electronic devices can I use to view the discussion
guide?
We tried to make this as universal as possible, so it
should work on your laptop (PC, Mac, Linux), your tablet (iPad,
Android), or your phone (iPhone, Android). It should also work on
many types of browsers (IE, Firefox, Chrome, Safari, Opera,
Dolphin,....). Please let us know if you have any problems, and we'll
troubleshoot with you (and improve the discussion guide for the next
go around).
- Why do I see weird characters in some places?
Because
we're joining data from many different sources, we do find some
technical challenges. This generally shows up as strange
characters--extra question marks, accented characters, or otherwise
unusual items. We've been able to fix many of these problems, but not
all. We ask that you bear with us as we improve this over
time!
Content
- What is included in the discussion guide?
There are
four sections within this document:
- Agenda, with summaries of each measure under
consideration
- Full information about each measure, including its
specifications, preliminary analysis of how this measure can
advance the program's goals, and the rationale by HHS for being
included in the list
- Summaries for each federal health program being
considered
- Public comments that have been received to date (Note that
the discussion guide may be released before the public comment
period is finished, in which case there will just be a
placeholder for where comments will go)
- How are the meeting discussions organized?
The meeting
sessions are organized around consent calendars, which are groups of
measures being considered for a particular program or groups of
measures for a particular condition or topic area. For each measure
being discussed, this document will show you the description, the
public comments (if any), the summary of the preliminary analysis,
and the result of the preliminary analysis algorithm.
Appendix E: Instructions for Joining the Meeting
Remotely
Remote Participation Instructions:
Streaming Audio Online
- Direct your web browser to: http://nqf.commpartners.com.
- Under “Enter a Meeting” type in the meeting number for Day 1:
###### or for Day 2: ###########
- In the “Display Name” field, type in your first and last names
and click “Enter Meeting.”
Teleconference
- Dial ### for workgroup members or ### for public participants ;
use conference ID code for Day 1: ###### or Day 2: ###### to access
the audio platform.