NQF

Version Number: 6.6
Meeting Date: January 24-25, 2017

Measure Applications Partnership
Coordinating Committee Discussion Guide

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Agenda

Agenda Synopsis

Day 1: January 24, 2017  
8:30 AM   Breakfast
9:00 AM   Welcome Remarks
9:15 AM   Review of Meeting Objectives
9:30 AM   MAP Pre-Rulemaking Approach
9:45 AM   NQF Strategic Plan
10:00 AM   Opportunity for Public Comment on Hospital Programs
10:15 AM   Pre-Rulemaking Recommendations for Hospital Programs
   Finalizing Workgroup Recommendations for All Hospital Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
12:00 PM   Lunch
12:30 AM   Opportunity for Public Comment on PAC/LTC Programs
12:45 PM   Pre-Rulemaking Recommendations for PAC/LTC Programs
   Finalizing Workgroup Recommendations for All PAC/LTC Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
2:30 PM   Break
2:45 PM   Opportunity for Public Comment on Clinician Programs
2:45 PM   Pre-Rulemaking Recommendations for Clinician Programs
   Finalizing Workgroup Recommendations for All Clinician Programs
   Measures Requiring a Vote on MAP's Preliminary Recommendation
5:00 PM   Adjourn for the Day

Day 2: January 25, 2017  
8:30 AM   Breakfast
9:00 AM   Day 1 Recap
9:15 AM   Pre-Rulemaking Cross-Cutting Issues: Attribution
10:45 AM   Break
11:00 AM   Refinements to the Medicaid Task Force Processes
11:45PM   Opportunity for Public Comment
12:00 PM   Lunch
12:30 PM   Potential Improvements to the Pre-Rulemaking Process
1:30 PM   Pre-Rulemaking Cross-Cutting Issues: Risk Adjustment for Sociodemographic Factors
2:30 PM   Opportunity for Public Comment
2:45 PM   Closing Remarks
3:00 PM   Adjourn


Full Agenda

Day 1: January 24, 2017  
8:30 AM   Breakfast
9:00 AM   Welcome Remarks
Kate Goodrich, Director and CMS Chief Medical Officer, Center for Clinical Standards and Quality, CMS


9:15 AM   Review of Meeting Objectives
Harold Pincus, MAP Coordinating Committee Co-Chair
Chip Kahn, MAP Coordinating Committee Co-Chair

9:30 AM   MAP Pre-Rulemaking Approach
Erin O’Rourke, Senior Director, NQF
Harold Pincus
  • Review the 2016-2017 MAP Pre-Rulemaking Approach


9:45 AM   NQF Strategic Plan
Helen Burstin, Chief Scientific Officer, NQF
Chip Kahn

10:00 AM   Opportunity for Public Comment on Hospital Programs
10:15 AM   Pre-Rulemaking Recommendations for Hospital Programs
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair
Ron Walters, MAP Hospital Workgroup Co-Chair
Melissa Mariñelarena, Senior Director, NQF
Harold Pincus
  • Discuss key themes from the Hospital Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Finalizing Workgroup Recommendations for All Hospital Programs
This section of the meeting finalizes the remaining workgroup recommendations for:
Lead Discussants: Rhonda Anderson, Leah Binder, Carole Flamm
Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
Lead Discussants:
  1. Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC16-155)
    • Description: This measure is for the risk-adjusted Standardized Infection Ratio (SIR) for all Surgical Site Infections (SSIs) following breast procedures conducted at ambulatory surgery centers (ASCs) among adult patients (ages 18 - 108 years) and reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measure compares the reported number of surgical site infections observed at an ASC with a predicted value based on nationally aggregated data. The measure was developed collaboratively by the CDC, the Ambulatory Surgery Center Quality Collaboration (ASC QC), and the Colorado Department of Public Health and Environment. CDC is the measure steward. (Measure Specifications)
    • Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
    • Public comments received: 3
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking on the condition that 1) the measure receive NQF endorsement and 2) additional testing and monitoring is conducted before the measure is used in a value-based purchasing (VBP) program.
    • Workgroup Recommendation: Conditional Support for Rulemaking


  2. Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures (MUC ID: MUC16-152)
    • Description: **As of 12/2 testing for this measure has been completed**** The measure score is an ASC-level rate of unplanned hospital visits within 7 days of an orthopedic procedure performed at an ASC. (Measure Specifications)
    • Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
    • Public comments received: 3
    • Workgroup Rationale: The Workgroup recommended that this measure be refined and resubmitted prior to rulemaking because it is currently undergoing field testing. The Workgroup agreed that testing results should demonstrate reliability and validity at the facility level in the ambulatory surgical setting. The Workgroup also recommended that this measure be submitted to NQF for review and endorsement.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  3. Hospital Visits after Urology Ambulatory Surgical Center Procedures (MUC ID: MUC16-153)
    • Description: **As of 12/2 testing for this measure has been completed**** The measure score is an ASC-level rate of unplanned hospital visits within 7 days of a urology procedure performed at an ASC. (Measure Specifications)
    • Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
    • Public comments received: 2
    • Workgroup Rationale: The Workgroup recommended that this measure be refined and resubmitted prior to rulemaking because it is currently undergoing field testing. The Workgroup agreed that testing results should demonstrate reliability and validity at the facility level in the ambulatory surgical setting. The Workgroup also recommended that this measure be submitted to NQF for review and endorsement.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  4. Hemodialysis Vascular Access: Long-term Catheter Rate (MUC ID: MUC16-309)
    • Description: Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: End-Stage Renal Disease Quality Incentive Program
    • Public comments received: 1
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking because it is intended to replace the existing dialysis catheter access measure in the ESRD QIP. This measure has been recommended for NQF endorsement by the Renal Standing Committee and ratified by the Executive Committee.
    • Workgroup Recommendation: Support for Rulemaking


  5. Standardized Transfusion Ratio for Dialysis Facilities (MUC ID: MUC16-305)
    • Description: The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: End-Stage Renal Disease Quality Incentive Program
    • Public comments received: 3
    • Workgroup Rationale: The Workgroup recommended that this measure be refined and resubmitted prior to rulemaking because dialysis facilities do not make decisions about administering blood transfusions to patients. The Workgroup noted that, in general, clinicians in hospitals make the decisions about blood transfusions. The Workgroup also discussed the variability in blood transfusion coding practices that could inadvertently affect a dialysis facility's performance on this measure.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  6. Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment at Discharge (MUC ID: MUC16-180)
    • Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 2
    • Workgroup Rationale: The Workgroup did not support this measure for rulemaking because no scientific evidence was provided demonstrating that patients who received a prescription at discharge for the treatment of alcohol or drug use disorder or a referral for addictions treatment received treatment after discharge.
    • Workgroup Recommendation: Do Not Support for Rulemaking


  7. Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention (MUC ID: MUC16-178)
    • Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included. These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]). (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 2
    • Workgroup Rationale: The Workgroup did not support this measure for rulemaking because there was no evidence demonstrating the impact of brief interventions on alchohol use. The Worgroup also noted that a large amount of effort is required manual chart abstraction needed to implement this measure and the potential benefit was not clearly established.
    • Workgroup Recommendation: Do Not Support for Rulemaking


  8. Communication about Pain During the Hospital Stay (MUC ID: MUC16-263)
    • Description: The following questions (or a subset of questions) would replace the current Pain Management measure in the HCAHPS Survey with a new measure(s). The following items were tested in early 2016. CMS is currently analyzing the results, as well as discussing these potential new pain management items with focus groups and hospital staff. Multi-item measure (composite): HP1: “During this hospital stay, did you have any pain?” HP2: “During this hospital stay, how often did hospital staff talk with you about how much pain you had?” HP3: “During this hospital stay, how often did hospital staff talk with you about how to treat your pain?” HP4: “During this hospital stay, did you get medicine for pain?” HP5: “Before giving you pain medicine, did hospital staff describe possible side effects in a way you could understand?” (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 7
    • Workgroup Rationale: The Workgroup recommended that this composite measure (HP1, HP2 and HP3) be revised and resubmitted prior to rulemaking because the measure has undergone field testing and is intended to replace the Pain Management composite measure in the HCAHPS Survey. The Workgroup emphasized the need to include non-pharmacological options used to treat pain. The Workgroup recommended that the testing results demonstrate reliability and validity for the Inpatient Quality Reporting (IQR) program. The Workgroup also recommended that the measure be submitted to NQF for review and endorsement.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  9. Completion of a Malnutrition Screening within 24 Hours of Admission (MUC ID: MUC16-294)
    • Description: Completion of a malnutrition screening using a validated screening tool to determine if a patient is at-risk for malnutrition, within 24 hours of admission to the hospital. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 3
    • Workgroup Rationale: The Workgroup recommended that this measure be revised and resubmitted prior to rulemaking because NQF’s Health and Well-Being Standing Committee recently reviewed the measure and did not reach consensus on the evidence provided to support it. The measure must pass the Evidence criterion and receive NQF endorsement. The Workgroup also encouraged the measure developer to test the individual malnutrition measures as a composite in an effort to balance the number of measures in the IQR yet fill the gap on malnutrition.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  10. Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 Hours of a Malnutrition Screening (MUC ID: MUC16-296)
    • Description: Patients age 65 years and older identified as at-risk for malnutrition based on a malnutrition screening who have a nutrition assessment documented in the medical record within 24 hours of the most recent malnutrition screening. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 10
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking with the condition that NQF's Health and Well-Being Standing Committee agrees that the evidence supporting this measure meets the Evidence criterion and the measure receives NQF endorsement. The Workgroup also encouraged the measure developer to test the individual malnutrition measures as a composite in an effort to balance the number of measures in the IQR yet fill the gap on malnutrition.
    • Workgroup Recommendation: Conditional Support for Rulemaking


  11. Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures (MUC ID: MUC16-262)
    • Description: The measure estimates the hospital-level quality of informed consent documents for elective procedures for fee-for-service (FFS) Medicare patients. The outcome is defined as the quality of the informed consent document, as evaluated using an instrument developed for this purpose, the Abstraction Tool. A sample of hospitals’ informed consent documents are evaluated and hospital-level performance will be derived by aggregating these individual informed consent document quality scores. The measure is broadly applicable to a range of procedures, including elective cardiac, orthopedic, and urological procedures, that are performed in the hospital. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 6
    • Workgroup Rationale: The Workgroup recommended that this measure be revised and resubmitted prior to rulemaking because it is the first step towards improving the practice of informed consent through quality measurement, and may compliment or serve as a platform for other measures of high-quality, patient-centered decision making. The Workgroup cautioned CMS about the potential data collection burden associated with this measure and the complexity of existing guidelines, regulations and state laws related to informed consent. The Workgroup recommended that the measure demonstrate reliability and validity at the facility level in the hospital setting. The Workgroup also recommended that the measure be submitted to NQF for review and endorsement.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  12. Medication Reconciliation at Admission (MUC ID: MUC16-049)
    • Description: **As of 12/2 testing for this measure has been completed**** ****Changed from requiring reconciliation within 24 hours to requiring reconciliation within 48 hours as of 12/1/16**** This measure assesses the average completeness of medication reconciliations conducted within 24 hours of admission to an inpatient facility. (Measure Specifications)
    • Programs under consideration: Inpatient Psychiatric Facility Quality Reporting Program
    • Public comments received: 4
    • Workgroup Rationale: The Workgroup recommended that this measure be refined and resubmitted prior to rulemaking because it is currently undergoing field testing. The Workgroup agreed that testing results should demonstrate reliability and validity at the facility level in the hospital setting. The Workgroup had a lengthy discussion about the intent of the measure (i.e., timeliness vs. accuracy of medication reconciliation) and chart abstraction burden. The Workgroup recommended that this measure be submitted to NQF for review and endorsement.
    • Workgroup Recommendation: Refine and Resubmit Prior to Rulemaking


  13. Proportion of patients who died from cancer admitted to hospice for less than 3 days (MUC ID: MUC16-274)
    • Description: Proportion of patients who died from cancer admitted to hospice for less than 3 days (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
    • Public comments received: 7
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking because enrolling cancer patients in hospice increases survival times and reduces resource use such as aggressive end of life care and hospital admissions. This measure was previously tested and NQF endorsed at the facility level in the hospital setting during the 2012 maintenance review. The Workgroup suggested that MUC16-274 and MUC16-275 be paired to encourage appropriate referral practices.
    • Workgroup Recommendation: Support for Rulemaking


  14. Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (MUC ID: MUC16-273)
    • Description: Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
    • Public comments received: 8
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking because a higher quality of life has been predicted in patients who avoid aggressive measures such as ICU stays in the last week of life. This measure was previously tested and NQF endorsed at the facility level in the hospital setting during the 2012 maintenance review.
    • Workgroup Recommendation: Support for Rulemaking


  15. Proportion of patients who died from cancer not admitted to hospice (MUC ID: MUC16-275)
    • Description: Proportion of patients who died from cancer not admitted to hospice (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
    • Public comments received: 6
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking because enrolling cancer patients in hospice increases survival times and reduces resource use such as aggressive end of life care and hospital admissions. This measure was previously tested and NQF endorsed at the facility level in the hospital setting during the 2012 maintenance review. The Workgroup suggested that MUC16-274 and MUC16-275 be paired to encourage appropriate referral practices.
    • Workgroup Recommendation: Support for Rulemaking


  16. Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (MUC ID: MUC16-271)
    • Description: Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
    • Public comments received: 5
    • Workgroup Rationale: The Workgroup supported this measure for rulemaking because it can reduce unnecessary treatment cancer patients receive at the end of life, which can negatively impact the patient and caregiver experience. This measure was previously tested and NQF endorsed at the facility level in the hospital setting during the 2012 maintenance review.
    • Workgroup Recommendation: Support for Rulemaking


  17. Safe Use of Opioids – Concurrent Prescribing (MUC ID: MUC16-167)
    • Description: Patients age 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge from a hospital-based encounter (inpatient, ED, outpatient) (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
    • Public comments received: 7
    • Workgroup Rationale: The Workgroup did not support this measure for rulemaking because there are many clinical conditions where concurrent prescriptions of opioids and benzodiazepines are appropriate. The Workgroup was also concerned that patients may unintentionally suffer withdrawal symptoms if previously prescribed opioids and/or benzodiazepines are reduced and/or stopped prior to discharge. The Workgroup also noted that the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain is not evidence-based.
    • Workgroup Recommendation: Do Not Support for Rulemaking


  18. Safe Use of Opioids – Concurrent Prescribing (MUC ID: MUC16-167)
    • Description: Patients age 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge from a hospital-based encounter (inpatient, ED, outpatient) (Measure Specifications)
    • Programs under consideration: Hospital Outpatient Quality Reporting Program
    • Public comments received: 6
    • Workgroup Rationale: The Workgroup did not support this measure for rulemaking because there are many clinical conditions where concurrent prescriptions of opioids and benzodiazepines are appropriate. The Workgroup was also concerned that patients may unintentionally suffer withdrawal symptoms if previously prescribed opioids and/or benzodiazepines are reduced and/or stopped prior to discharge. The Workgroup also noted that the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain is not evidence-based.
    • Workgroup Recommendation: Do Not Support for Rulemaking


12:00 PM   Lunch
12:30 AM   Opportunity for Public Comment on PAC/LTC Programs
12:45 PM   Pre-Rulemaking Recommendations for PAC/LTC Programs
Deb Saliba, MAP PAC/LTC Workgroup Co-Chair
Jean-Luc Tilly, Project Manager, NQF
Harold Pincus
  • Discuss key themes from the PAC/LTC Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Finalizing Workgroup Recommendations for All PAC/LTC Programs
This section of the meeting finalizes the remaining workgroup recommendations for:
Lead Discussants: David Gifford, Ari Robicsek
Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
Lead Discussants:
  1. The Percent of Residents or Home Health Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (MUC ID: MUC16-145)
    • Description: This quality measure reports the percent of Home Health patient episodes with Stage 2-4 or unstageable pressure ulcers that are new or worsened since Start of Care (SOC) or Resumption of Care (ROC). (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Home Health Quality Reporting Program
    • Public comments received: 1
    • Workgroup Rationale: MAP supported the measure of new or worsened pressure ulcers. MAP cited the severity of pressure ulcers and their effect on quality of life and pain, and the fact that they are largely preventable, as compelling reasons to implement a performance measure. MAP also noted the measure is endorsed (NQF#678), material changes to the measure improve the specifications and it is currently implemented in the SNF QRP, LTCH QRP, and IRF QRP programs.
    • Workgroup Recommendation: Support


  2. Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (MUC ID: MUC16-143)
    • Description: This quality measure reports the percent of IRF patient stays with Stage 2-4 or unstageable pressure ulcers that are new or worsened since admission (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Inpatient Rehabilitation Facility Quality Reporting Program
    • Public comments received: 5
    • Workgroup Rationale: MAP conditionally supported the measure of new or worsened pressure ulcers. MAP cited the severity of pressure ulcers and their effect on quality of life and pain, and the fact that they are largely preventable, as compelling reasons to implement a performance measure. While MAP noted the measure is endorsed (NQF#678), and is currently implemented in the SNF QRP, LTCH QRP, and IRF QRP programs concerns were raised about the impact of the material revisions to the measure for the IRF setting. MAP considered feedback that suggested that pressure ulcers have very low (approximately 1%) incidence, and that a change in the data calculation method and data source may lead to inconsistent results. MAP suggested the measure be examined to better understand the impact of the measure revisions and relevance in the IRF population.
    • Workgroup Recommendation: Conditional Support


2:30 PM   Break
2:45 PM   Opportunity for Public Comment on Clinician Programs
2:45 PM   Pre-Rulemaking Recommendations for Clinician Programs
Bruce Bagley, MAP Clinician Workgroup Chair
Eric Whitacre, MAP Clinician Workgroup Chair
John Bernot, Senior Director, NQFF
Chip Kahn
  • Discuss key themes from the Clinician Workgroup meeting
  • Review and finalize broader guidance about programmatic issues
  • Review and discuss input from the MAP Dual Eligible Beneficiaries Workgroup
  • Review and finalize workgroup measure recommendations


Finalizing Workgroup Recommendations for All Clinician Programs
This section of the meeting finalizes the remaining workgroup recommendations for:
Lead Discussants: Carl Sirio, Aparna Higgins, Chris Queram
Measures Requiring a Vote on MAP's Preliminary Recommendation
This section of the meeting includes debate and voting on measures pulled by MAP Coordinating Committee members.
Lead Discussants:
  1. HIV Medical Visit Frequency (MUC ID: MUC16-073)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. (The endorsed specifications of the measure are: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visitsA medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Workgroup Rationale: This measure addresses an important clinical area. However, it has not been fully tested as an e-CQM. Additionally, the performance data is in the process of being updated from the 2011 data. Since this is a process measure, MAP is interested in whether that test data continues to show variation and room for improvement in the measure. MAP acknowledged that this measure is part of a continuum of care; however, they prefer that outcome measures be used to monitor HIV. MAP recommended that if an outcome measure is not feasible at this time, that the measure be resubmitted after it has been fully tested as an e-CQM with data demonstrating that a performance gap continues to exist.
    • Workgroup Recommendation: Refine and resubmit


  2. Prescription of HIV Antiretroviral Therapy (MUC ID: MUC16-072)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed HIV antiretroviral therapy for the treatment of HIV infection during the measurement year. (The endorsed specifications of the measure are: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement yearA medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 0
    • Workgroup Rationale: Though an important clinical area, the measure does not support alignment as CMS has removed the related, paper measure, NQF#2083. Additionally, the performance data is in the process of being updated from the 2011 data. Since this is a process measure, MAP is interested in whether that test data continues to show variation and room for improvement in the measure. MAP acknowledged that this measure is part of a continuum of care; however, they prefer that outcome measures be used to monitor HIV. MAP recommended that if an outcome measure is not feasible at this time, that the measure be resubmitted after it has been fully tested as an e-CQM with data demonstrating that a performance gap continues to exist. Additionally, MAP recommends that the alignment issue be addressed as part of resubmission.
    • Workgroup Recommendation: Refine and resubmit


5:00 PM   Adjourn for the Day

Day 2: January 25, 2017  
8:30 AM   Breakfast
9:00 AM   Day 1 Recap
Chip Kahn
Harold Pincus

9:15 AM   Pre-Rulemaking Cross-Cutting Issues: Attribution
Harold Pincus
Taroon Amin, Consultant, NQF
Erin O’Rourke
Helen Burstin
  • Findings from the Attribution Committeel
  • Off-label measure use
  • Shared accountability in context of setting-specific programs


10:45 AM   Break
11:00 AM   Refinements to the Medicaid Task Force Processes
Debjani Mukherjee, Senior Director, NQF

11:45PM   Opportunity for Public Comment
12:00 PM   Lunch
12:30 PM   Potential Improvements to the Pre-Rulemaking Process
Kim Ibarra, Senior Project Manager, NQF
  • Round-Robin Plus/Delta
  • Input on improving the review of current measure sets
  • Feedback loops


1:30 PM   Pre-Rulemaking Cross-Cutting Issues: Risk Adjustment for Sociodemographic Factors
Karen Joynt, Senior Advisor to the Deputy Assistant Secretary for Planning and Evaluation, Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Nancy De Lew, Acting Deputy Assistant Secretary, ASPE
Kate Goodrich
Helen Burstin
Chip Kahn
  • Update on 21st Century Cures Act
  • Request from CSAC
  • Implications of the ASPE Report


2:30 PM   Opportunity for Public Comment
2:45 PM   Closing Remarks
Chip Kahn
Harold Pincus

3:00 PM   Adjourn

Appendix A: Measure Information

Measure Index

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Home Health Quality Reporting Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Hospice Quality Reporting Program

Hospital Value-Based Purchasing Program

Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Rehabilitation Facility Quality Reporting Program

Long-Term Care Hospital Quality Reporting Program

Merit-Based Incentive Payment System

Medicare Shared Savings Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program

Skilled Nursing Facility Quality Reporting Program

Full Measure Information

Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-155)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Breast SSIs contribute a substantial portion of SSI in inpatient settings, and also have the one of the highest risk of any procedure type in outpatient settings. In the Netherlands, the rate of SSI following mastectomies in 2006 was 61% as determined by a study in 2006 (Mannien, 2006). A case control study performed in 2004 reported SSI rates following breast surgeries to be 25.8% (Vilar-Compte, 2004). One study of breast SSI risk in an HOPD reported an overall risk of 5.2%, with procedure-specific risks of 12.4% following mastectomy with immediate implant reconstruction, 6.2% following mastectomy with immediate reconstruction using a transverse rectus abdominis myocutaneous flap, 4.4% following mastectomy only, and 1.1% following breast reduction surgery (Olsen, 2008). Another study of SSI following breast cancer-related procedures reported a risk of 18.9% (Vilar-Compte, 2009). The cost incurred by each breast SSI attributable to the SSI was estimated by one analysis to be $4,901 per patient (Olsen, 2008). Though these estimates of risk vary from 1% to over 30% depending on procedure type, sample population, and definition of SSI, it is clear that breast procedure-related SSIs are a large burden to outpatient healthcare facilities. From 1980-1995, a significant trend in surgery was the transition from inpatient settings to outpatient ambulatory surgery settings due to advances in surgical techniques and economic incentives for ambulatory surgery (Kozak, 1999). In the current literature, the rates of SSI in ambulatory surgery centers is relatively low—however, aggregate numbers of infections can still cause a substantial burden, as those often result in post-surgical visits and morbidity. ASCs have been shown to have a lower SSI rate than inpatient settings; in one study, SSI morbidity and recurrence rates in ambulatory surgery were half the rates in inpatient surgery. A 5-year study of SSIs in ambulatory surgery centers showed a rate of 2.8 SSI per 100 surgeries (Vilar-Compte, 2001). These rates are relatively consistent- another study reported a risk of SSI after outpatient surgery to be 3.5% (Grøgaard, 2001). Aside from morbidity alone, postsurgical visits due to SSI acquired during surgery contribute much to the cost burden on healthcare facilities. A study on postsurgical acute care visits for SSIs in ASCs demonstrated a rate of 3.09 SSI-related visits per 1000 procedures at 14 days after surgery and 4.84 per 1000 at 30 days after surgery (Owens, 2014). References Mannien, J., Wille, J. C., Snoeren, R. L., & Hof, S. V. (2006). Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures: Results From the Nosocomial Surveillance Network in The Netherlands. Infection Control and Hospital Epidemiology Infect Control Hosp Epidemiol, 27(8), 809-816. Volkow, P., Vilar-Compte, D., Jacquemin, B., & Robles-Vidal, C. (2004). Surgical Site Infections in Breast Surgery: Case-control Study. World Journal of Surgery, 28(3), 242-246. Vilar-Compte, D., Rosales, S., Hernandez-Mello, N., Maafs, E., & Volkow, P. (2009). Surveillance, Control, and Prevention of Surgical Site Infections in Breast Cancer Surgery: A 5-year Experience. American Journal of Infection Control, 37(8), 674-679. Olsen, M. A., et al. (2008). Hospital-Associated Costs Due to Surgical Site Infection After Breast Surgery. Arch Surg Archives of Surgery, 143(1), 53-60. Kozak LJ, McCarthy E, Pokras R. (1999). Changing Patterns of Surgical Care in the United States, 1980-1995. Health Care Financ Rev, 21(1), 31-49. Vilar-Compte D, Roldán R, Sandoval S, et al. (2001). Surgical Site Infections in Ambulatory Surgery: A 5-year Experience. American Journal of Infection Control, 29(2), 99-103. Grøgaard, B. (2001). Wound Infection in Day-surgery. Ambulatory Surgery, 9(2), 109-112. Owens PL, Barrett ML, Raetzman S, Maggard-Gibbons M, Steiner CA. (2014). Surgical Site Infections Following Ambulatory Surgery Procedures. Jama, 311(7), 709-716.

Measure Specifications




Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-152)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Improving the quality of care provided at ASCs is a key priority in the context of growth in the number of ASCs and procedures performed in this setting. More than 60% of all medical or surgical procedures were performed at ASCs in 2006 – a three-fold increase from the late 1990s (Cullen et al. 2009). In 2013, more than 3.4 million Fee-for-Service (FFS) Medicare beneficiaries were treated at 5,364 Medicare-certified ASCs, and spending on ASC services by Medicare and its beneficiaries amounted to $3.7 billion (Medicare Payment Advisory Commission 2015). The patient population served at ASCs has increased not only in volume but also in age and complexity, which can be partially attributed to improvements in anesthetic care and innovations in minimally invasive surgical techniques (Bettelli 2009; Fuchs 2002). ASCs have become the preferred setting for the provision of low-risk surgical and medical procedures in the US, as many patients experience shorter wait times, prefer to avoid hospitalization, and are able to return rapidly to work (Cullen et al. 2009). Therefore, in the context of growth in volume and diversity of procedures performed at ASCs, evaluating the quality of care provided at ASCs is increasingly important. As the number of orthopedic procedures increase in ASCs, it is important to evaluate the quality of care for patients undergoing these procedures. According to Medicare claims, approximately 7% of surgeries performed at ASCs were orthopedic in nature in 2007, which reflects a 77% increase in orthopedic procedures performed at ASCs from 2000 to 2007 (Goyal et al. 2016). Measuring and reporting seven-day unplanned hospital visits following orthopedic procedures will incentivize ASCs to improve care and care transitions. Many of the reasons for hospital visits are preventable. Patients often present to the hospital for complications of medical care, including infection, post-operative bleeding, urinary retention, nausea and vomiting, and pain. Martín-Ferrero et al. (2014) found that of 10,032 patients who underwent ambulatory orthopedic surgical procedures at an ambulatory surgery unit between June 1993 and June 2012, 121 (1.2%) patients needed attention in the emergency department during the first 24 hours after discharge because of pain (86 patients) or bleeding (35 patients). There were five subsequent hospitalizations for knee pain and swelling (Martín-Ferrero and Faour- Martín 2014). In conclusion, acute care visits following orthopedic surgery are an important and measurable outcome for surgeries and procedures performed at ASCs. Many of these unanticipated acute care visits occur at or after discharge and may not be readily visible to clinicians because patients often present to alternative facilities, such as emergency departments. Therefore, illuminating these events should facilitate efforts to improve patient outcomes following ASC procedures. Bettelli G. High risk patients in day surgery. Minerva anestesiologica. 2009;75(5):259-268. Cullen KA, Hall MJ, Golosinskiy A, Statistics NCfH. Ambulatory surgery in the United States, 2006. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2009. Fuchs K. Minimally invasive surgery. Endoscopy. 2002;34(2):154-159. Goyal KS, Jain S, Buterbaugh GA, et al. The safety of hang and upper-extremity surgical procedures at a freestanding ambulatory surgical center. The Journal of Bone and Joint Surgery. 2016;90:600-4. Martín-Ferrero MÁ, Faour- Martín O. Ambulatory surgery in orthopedics: experience of over 10,000 patients. Journal of Orthopaedic Surgery. 2014;19:332-338. Medicare Payment Advisory Commission (MedPAC). Report to Congress: Medicare Payment Policy. March 2015; http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf?sfvrsn=0.

Measure Specifications




Hospital Visits after Urology Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-153)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Improving the quality of care provided at ASCs is a key priority in the context of growth in the number of ASCs and procedures performed in this setting. More than 60% of all medical or surgical procedures are performed at ASCs in 2006 – a three-fold increase since the late 1990s (Cullen et al. 2009). In 2013, more than 3.4 million Fee-for-Service (FFS) Medicare beneficiaries were treated at 5,364 Medicare-certified ASCs, and spending on ASC services by Medicare and its beneficiaries amounted to $3.7 billion (Medicare Payment Advisory Commission 2015). The patient population served at ASCs has increased not only in volume but also in age and complexity, which can be partially attributed to improvements in anesthetic care and innovations in minimally invasive surgical techniques (Bettelli 2009; Fuchs 2002). ASCs have become the preferred setting for the provision of low-risk surgical and medical procedures in the US, as many patients experience shorter wait times, prefer to avoid hospitalization, and are able to return rapidly to work (Cullen et al. 2009). Therefore, in the context of growth in volume and diversity of procedures performed at ASCs, evaluating the quality of care provided at ASCs is increasingly important. As the number of urology procedures increases in ASCs, it is important to evaluate the quality of care for patients undergoing these procedures. A 1998 study found that urology procedures accounted for 4.8% of unanticipated admissions and was almost twice as likely as orthopedics, plastic surgery, or neurosurgery to have admissions (Fortier 1998). Similarly, a 2014 study found that outpatient urology surgery had an overall 3.7% readmission rate (Rambachan 2014). Using 5% national samples of Medicare FFS beneficiaries aged =65 years from 1998 to 2006, Hollingsworth et al. (2012) reported 30-day adjusted outcome rates for patients who underwent one of 22 common outpatient urologic procedures at ASCs. The 30-day adjusted rate of inpatient admission was 7.9% (0.4% same-day admission and 7.5% subsequent admission). Risk-adjustment variables included age, gender, race, comorbid status (assessed using an adaptation of the Charlson index), area of residence, and calendar year. Multivariable logistic regression analyses used robust variance estimators (Hollingsworth 2012). The study found that more frequent same-day admissions follow outpatient surgery at ASCs vs. hospitals. Since urology procedure in the ASC is a significant predictive factor for unanticipated admissions compared to other procedures (Fortier 1998), measuring and reporting seven-day unplanned hospital visits following urology procedures will incentivize ASCs to improve care and care transitions. Many of the reasons for hospital visits are preventable. Patients often present to the hospital for complications of medical care, including urinary tract infection, calculus of ureter, urinary retention, hematuria, and septicemia. However, patient and staff education is an opportunity to improve the success rate of urology procedures in the ASC (Paez 2007). Using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP), Owens et al. (2014) reported unadjusted outcomes for low-risk patients undergoing five types of low- to moderate-risk surgical procedures, including urology procedures (Owens 2014). The outcomes of interest included 14- and 30-day all-cause acute care visit rates. Acute care visits included subsequent ambulatory surgery visits and inpatient admissions; the authors specifically excluded ED visits that did not result in hospitalization from the outcome. The 14- and 30-day rates of transurethral prostatectomy acute care visits were 0.11% and .18%, respectively. In conclusion, acute care visits following urology surgery are an important and measurable outcome for surgeries and procedures performed at ASCs. Many of these unanticipated acute care visits occur at or after discharge and may not be readily visible to clinicians because patients often present to alternative facilities, such as emergency departments. Therefore, illuminating these events should facilitate efforts to improve patient outcomes following ASC procedures. Bettelli G. High risk patients in day surgery. Minerva anestesiologica. 2009;75(5):259-268. Cullen KA, Hall MJ, Golosinskiy A, Statistics NCfH. Ambulatory surgery in the United States, 2006. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2009. Fortier J. Unanticipated admission after ambulatory surgery--a prospective study. Can J Anaesth. 1998;45(7):612-9. Fuchs K. Minimally invasive surgery. Endoscopy. 2002;34(2):154-159. Hollingsworth JM. Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. The Journal of Urology. 2012;188(4):1274-1278. Medicare Payment Advisory Commission (MedPAC). Report to Congress: Medicare Payment Policy. March 2015; http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf?sfvrsn=0. Owens PLPL. Surgical site infections following ambulatory surgery procedures. JAMA : the journal of the American Medical Association. 2014;311(7):709-716. Paez A. Adverse events and readmissions after day-case urological surgery. International Braz J Urol. 2007;33(3):330-8. Rambachan A. Predictors of readmission following outpatient urological surgery Annals of the Royal College of Surgeons of England. Journal of Urology. 2014; 192(1):183-188.

Measure Specifications




Hemodialysis Vascular Access: Long-term Catheter Rate (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-309)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The 2006 Clinical Practice Guidelines for Vascular Access is an update to the original vascular access guidelines published in 1997 by the National Kidney Foundation. In the eight years that the literature review included for the update, there have been no randomized controlled trials for type of vascular access. Specifically, for the guideline used to support this measure, a total of 84 peer-reviewed publications are included in the body of evidence presented. While these are all observational studies, some are based on either national data such as the United States Renal Data System (USRDS) that includes all patients with end stage kidney disease in the US, or international data, such as the Dialysis Outcomes Practice Pattern Study (DOPPS) that provides a global perspective for US vascular access outcomes. The overall quality of evidence is moderately strong. All studies are in the target population of hemodialysis patients. Some studies have evaluated health outcomes such as patient mortality, but have limitations due to the observational nature of the design. Other studies have more rigorous design, but use surrogate outcomes such as access thrombosis. The 12 studies listed below highlight the core benefits associated with using an AV fistula or graft such as reduced mortality and morbidity relative to using a tunneled catheter. Specifically, AV fistula have: • Lowest Cost1-3: Compared to catheters, Medicare expenditures for AVF are approximately $17,000 less per person per year. • Lowest rates of infection: AV fistula have the lowest rates of infection followed by AV grafts and then tunneled dialysis catheters4. Vascular access infections are common, and represent the second most common cause of death for patients receiving hemodialysis.5 • Lowest mortality and hospitalization: Patients using catheters (RR=2.3) and grafts (RR=1.47) have a greater mortality risk than patients dialyzed with fistulae6-9. Other studies have also found that use of fistulae reduces mortality and morbidity10-12 compared to AV grafts or catheters. References: 1. Mehta S: Statistical summary of clinical results of vascular access procedures for haemodialysis, in Sommer BG, Henry ML (eds): Vascular Access for Hemodialysis-II (ed 2). Chicago, IL, Gore, 1991, pp 145-157 2. The Cost Effectiveness of Alternative Types of Vascular access and the Economic Cost of ESRD. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1995, pp 139-157 3. Eggers P, Milam R: Trends in vascular access procedures and expenditures in Medicare’s ESRD program, in Henry ML (ed): Vascular Access for Hemodialysis-VII. Chicago, IL, Gore, 2001, pp 133-143 4. Nassar GM, Ayus JC: Infectious complications of the hemodialysis access. Kidney Int 60:1-13, 2001 5. Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A, Pandey CM: Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 25:967-973, 2003 6. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK: Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60:1443-1451, 2001 7. Woods JD, Port FK: The impact of vascular access for haemodialysis on patient morbidity and mortality. Nephrol Dial Transplant 12:657-659, 1997 8. Xue JL, Dahl D, Ebben JP, Collins AJ: The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis 42:1013-1019, 2003 9. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG: Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol 15:477-486, 2004 10. Huber TS, Carter JW, Carter RL, Seeger JM: Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: A systematic review. J Vasc Surg 38(5):1005-11, 2003 11. Perera GB, Mueller MP, Kubaska SM, Wilson SE, Lawrence PF, Fujitani RM: Superiority of autogenous arteriovenous hemodialysis access: Maintenance of function with fewer secondary interventions. Ann Vasc Surg 18:66-73, 2004 12. Pisoni RL, Young EW, Dykstra DM, et al: Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int 61:305-316, 2002

Measure Specifications

Summary of NQF Endorsement Review




Hemodialysis Vascular Access: Standardized Fistula Rate (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-308)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The 2006 Clinical Practice Guidelines for Vascular Access is an update to the original vascular access guidelines published in 1997 by the National Kidney Foundation. In the eight years that the literature review included for the update, there have been no randomized controlled trials for type of vascular access. Specifically, for the guideline used to support this measure, a total of 84 peer-reviewed publications are included in the body of evidence presented. While these are all observational studies, some are based on either national data such as the United States Renal Data System (USRDS) that includes all patients with end stage kidney disease in the US, or international data, such as the Dialysis Outcomes Practice Pattern Study (DOPPS) that provides a global perspective for US vascular access outcomes. The overall quality of evidence is moderately strong. All studies are in the target population of hemodialysis patients. Some studies have evaluated health outcomes such as patient mortality, but have limitations due to the observational nature of the design. Other studies have more rigorous design, but use surrogate outcomes such as access thrombosis. The 12 studies listed below highlight the core benefits such as reduced mortality and morbidity associated with using an AV fistula relative to either an AV graft or a tunneled catheter. Specifically, AV fistulae have: • Lowest risk of thrombosis: in a systematic review of 34 studies evaluating access patency, AVF were found to have superior primary patency at 18 months compared to AV grafts (51% vs. 33%).1 • Lowest rate of angioplasty/intervention: Procedure rates have been reported as 0.53 procedures/patient/year for AV fistula compared to 0.92 procedures/patient/year for AV grafts.2 • Longest survival: Case-mix adjusted survival analysis indicated substantially better survival of AV fistula compared with AV grafts in the US [risk ratios (RR) of failure 0.56, P < 0.0009]3 • Lowest Cost4-6: Based on 1990 costs to Medicare, graft recipients cost HCFA (CMS) $3,700 more than fistula patients when pro-rating graft reimbursements to the median fistula survival time.5 • Lowest rates of infection: AV fistula have the lowest rates of infection followed by AV grafts and then tunneled dialysis catheters7. Vascular access infections are common, and represent the second most common cause of death for patients receiving hemodialysis.8 • Lowest mortality and hospitalization: Patients using catheters (RR=2.3) and grafts (RR=1.47) have a greater mortality risk than patients dialyzed with fistulae9. Other studies have also found that use of fistulae reduces mortality and morbidity10-12 compared to AV grafts or catheters. References: 1. Huber TS, Carter JW, Carter RL, Seeger JM: Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: A systematic review. J Vasc Surg 38(5):1005-11, 2003 2. Perera GB, Mueller MP, Kubaska SM, Wilson SE, Lawrence PF, Fujitani RM: Superiority of autogenous arteriovenous hemodialysis access: Maintenance of function with fewer secondary interventions. Ann Vasc Surg 18:66-73, 2004 3. Pisoni RL, Young EW, Dykstra DM, et al: Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int 61:305-316, 2002 4. Mehta S: Statistical summary of clinical results of vascular access procedures for haemodialysis, in Sommer BG, Henry ML (eds): Vascular Access for Hemodialysis-II (ed 2). Chicago, IL, Gore, 1991, pp 145-157 5. The Cost Effectiveness of Alternative Types of Vascular access and the Economic Cost of ESRD. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1995, pp 139-157 6. Eggers P, Milam R: Trends in vascular access procedures and expenditures in Medicare’s ESRD program, in Henry ML (ed): Vascular Access for Hemodialysis-VII. Chicago, IL, Gore, 2001, pp 133-143 7. Nassar GM, Ayus JC: Infectious complications of the hemodialysis access. Kidney Int 60:1-13, 2001 8. Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A, Pandey CM: Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 25:967-973, 2003 9. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK: Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60:1443-1451, 2001 10. Woods JD, Port FK: The impact of vascular access for haemodialysis on patient morbidity and mortality. Nephrol Dial Transplant 12:657-659, 1997 11. Xue JL, Dahl D, Ebben JP, Collins AJ: The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis 42:1013-1019, 2003 12. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG: Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol 15:477-486, 2004

Measure Specifications

Summary of NQF Endorsement Review




Standardized Transfusion Ratio for Dialysis Facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-305)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The Medicare ESRD Program requires Medicare certified dialysis facilities to manage the anemia of CKD as one of their responsibilities under the Conditions for Coverage (1). In addition, the Medicare ESRD Program has included payment for ESAs in dialysis facility reimbursement since 1989. It is notable that inclusion of ESAs in dialysis program payment was associated with a dramatic reduction in the use of blood transfusions in the US chronic dialysis population (2-3). Recently, reliance on achieved hemoglobin concentration as an indicator of successful anemia management in this population has been de-emphasized and use of other clinically meaningful outcomes, such as transfusion avoidance, have been recommended as alternate measures of anemia management (4-7). Best dialysis provider practice should include effective anemia management algorithms that focus on 1) prevention and treatment of iron deficiency, inflammation and other causes of ESA resistance, 2) use of the lowest dose of ESAs that achieves an appropriate target hemoglobin that is consistent with FDA guidelines and current best practices, and 3) education of patients, their families and medical providers to avoid unnecessary blood transfusion so that risk of allosensitization is minimized, eliminating or reducing one preventable barrier to successful kidney transplantation. The decision to transfuse blood is intended to improve or correct the pathophysiologic consequences of severe anemia, defined by achieved hemoglobin or hematocrit%, in a specific clinical context for each patient situation (8). Consensus guidelines in the U.S. and other consensus guidelines defining appropriate use of blood transfusions are based, in large part, on the severity of anemia (9-11). Given the role of hemoglobin as a clinical outcome that defines anemia as well as forms a basis for consensus recommendations regarding use of blood transfusion, it is not surprising that the presence of decreased hemoglobin concentration is a strong predictor of subsequent risk for blood transfusion in multiple settings, including chronic dialysis (12-21). For example, Gilbertson, et al found a nearly four-fold higher risk-adjusted transfusion rate in dialysis patients with achieved hemoglobin <10 gm/dl compared to those with >10 gm/dl hemoglobin. (19) In addition to achieved hemoglobin, other factors related to dialysis facility practices, including the facility’s response to their patients achieved hemoglobin, may influence blood transfusion risk in the chronic dialysis population (22, 25). In an observational study recently published by Molony, et al (2016) comparing different facility level titration practices, among patients with hemoglobin <10 and those with hemoglobin>11, they found increased transfusion risk in patients with larger ESA dose reductions and smaller dose escalations, and reduced transfusion risk in patients with larger ESA dose increases and smaller dose reductions (25). The authors reported no clinically meaningful differences in all-cause or cause-specific hospitalization events across groups. The Food and Drug Administration position defining the primary indication of ESA use in the CKD population is for transfusion avoidance, reflecting the assessment of the relative risks and benefits of ESA use versus blood transfusion. Several historical studies, and one recent research study reviewed by Obrador and Macdougall, document the specific risks of allosensitization after blood transfusion and the potential for transfusion-associated allosensitization to interfere with timely kidney transplantation. (23) A recent analysis demonstrated increased odds ratios for allosensitization associated with transfusion, particularly for men and parous women. That study also demonstrated a 28% reduction in likelihood of transplantation in transfused individuals, based on a multivariate risk-adjusted statistical model. (24)

Measure Specifications

Summary of NQF Endorsement Review




The Percent of Home Health Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Program: Home Health Quality Reporting Program; MUC ID: MUC16-061)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
See literature for NQF# 2631 about the importance of the admission and discharge functional assessment and a care plan that addresses function among home health patients and developing interventions.

Measure Specifications

Summary of NQF Endorsement Review




The Percent of Home Health Residents Experiencing One or More Falls with Major Injury (Program: Home Health Quality Reporting Program; MUC ID: MUC16-063)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Falls are prevalent among community-dwelling older adults and a major source of morbidity and mortality; see the literature for NQF #0674.

Measure Specifications

Summary of NQF Endorsement Review




The Percent of Residents or Home Health Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Home Health Quality Reporting Program; MUC ID: MUC16-145)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Measure Specifications

Summary of NQF Endorsement Review




Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Home Health Quality Reporting Program; MUC ID: MUC16-347)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications




Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Home Health Quality Reporting Program; MUC ID: MUC16-357)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications




Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-180)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
In a study on the provision of evidence-based care and preventive services provided in hospitals for 30 different medical conditions, quality varied substantially according to diagnosis. Adherence to recommended practices for treatment of substance use ranked last, with only 10% of patients receiving proper care (McGlynn 2003, Gentilello 2005). Currently, less than one in twenty patients with an addiction are referred for treatment (Gentilello 1999). Unfortunately, many physicians mistakenly believe that substance use problems are largely confined to the young. They are significantly less likely to recognize an alcohol problem in an older patient than in a younger one. (Curtis 1989) As a result, these problems usually go undetected, resulting in harmful, expensive, and sometimes even catastrophic consequences. This is demonstrated by the fact that few older adults who need substance use treatment actually receive it. In 2005, persons 65 years and older made up only 11,344 out of 1.8 million substance use treatment episodes recorded.(SAMHSA 2007) • Gentilello LM, Ebel BE, Wickizer TM, Salkever DS Rivera FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Ann Surg. 2005 Apr;241(4):541-50. • Gentilello LM, Villaveces A, Ries RR, Nason KS, Daranciang E, Donovan DM Copass M, Jurkovich GJ Rivara FP. Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma. 1999 Dec;47(6):1131-5; discussion 1135-9. • McGlynn, EA, Asch SM, Adams J, Keesey J, et al. The New England Journal of Medicine. Boston: Jun 26, 2003. Vol. 348, Iss.26; pg. 2635, 11pgs. • Curtis, J.R.; Geller, G.; Stokes, E.J. ; et al. Characteristics, diagnosis, and treatment of alcoholism in elderly patients. J Am Geriatr Soc 37:310-316, 1989. • SAMHSA. Office of Applied Studies. Older adults in substance abuse treatment: 2005. The DASIS Report. Rockville MD, November 8, 2007.

Measure Specifications

Summary of NQF Endorsement Review




Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-178)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Excessive use of alcohol has a substantial harmful impact on health and society in the United States. It is a drain on the economy and a source of enormous personal tragedy. In 2010, excessive alcohol use cost the US economy $249 billion, or $2.05 a drink, and $2 of every $5 of these costs were paid by the public. More than 537,000 persons died as a consequence of alcohol, drug, and tobacco use, making them the cause of more than one out of four deaths in the United States.1 Excessive alcohol use places drinkers, their families, and their communities at risk for many harmful health effects, including: Chronic conditions. Over time, excessive drinking can lead to high blood pressure, various cancers, heart disease, stroke, and liver disease. Sexual risk behaviors. Excessive drinking increases sexual risk behaviors, which can result in unintended pregnancy, HIV infection, and other sexually transmitted diseases. Motor vehicle crashes. Excessive drinking can lead to motor vehicle crashes, resulting in injuries and deaths. Binge drinkers are responsible for most of the alcohol-impaired driving episodes involving US adults. Violence and injuries. Excessive alcohol use can lead to falls, drowning, homicide, suicide, intimate partner violence, and sexual assault. Fetal alcohol spectrum disorders. Any alcohol use by a pregnant woman can harm a developing fetus, resulting in physical, behavioral, and learning problems later in life. Hospitalization provides a prime opportunity to address substance use, and for many patients, controlling their other health problems requires addressing their substance use.2 Approximately 8% of general hospital inpatients and 40 to 60% of traumatically injured inpatients and psychiatric inpatients have substance use disorders. 3 1. Mokdad AH, Marks JS, Stroup DS, Geberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:128-1245. 2. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: Long-term efficacy and cost-benefit analysis. Alcohol Clin Exp Res. 2002 Jan;26(1):36-43. 3. Gentilello LM, Villaveces A, Ries RR, Nason KS, Daranciang E, Donovan DM, Copass M, Jurkovick GJ, Rivara FP. Detection of acute intoxication and chronic alcohol dependence by trauma center staff. J Trauma. 1999 Dec;47(6):1131-5; discussion 1135-9.

Measure Specifications

Summary of NQF Endorsement Review




Alcohol Use Screening (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-179)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
It was the expert opinion of our advisory panel that implementation of this measure would lead to the provision of brief interventions for patients at risk for excessive alcohol use and alcohol-related harms. Evidence-based screening instruments exist that can detect harmful alcohol use. Brief interventions that can be delivered during a single primary care office visit have been tested in multiple randomized trials, including a multi-center one in the Medicare eligible age group. They demonstrate that screening and intervention significantly reduce health risks, and generate cost savings of approximately $4 dollars for every dollar invested in providing them. (Fleming 1999) Clinical trials have demonstrated that brief interventions, especially prior to the onset of addiction, significantly improve health and reduce costs, and that similar benefits occur in those with addictive disorders who are referred to treatment (SAMHSA 2007, NIAAA 2005, Fleming 2002). Yet, according to a recent study by CDC and SAMHSA, 9 in 10 excessive drinkers are not alcohol dependent (Esser MB, Hedden SL, Kanny D, Brewer RD, Gfroerer JC, Naimi TS. Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009–2011. Prev Chronic Dis 2014;11:140329).

Measure Specifications

Summary of NQF Endorsement Review




Appropriate Documentation of a Malnutrition Diagnosis (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-344)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The diagnosis of malnutrition via the completion of a nutrition assessment in patients at-risk of malnutrition can assist clinicians in identifying the appropriate interventions addressing patients’ malnourished state (White, 2011; Mueller, 2011; Kruizenga, 2005). Current estimates of the prevalence of adult malnutrition range from 15%-60% depending on the patient population and criteria used to identify its occurrence (Mueller, 2011). While this reflects a large portion of the population, only around 3 percent of patients are diagnosed with malnutrition; in turn, it is estimated that 4-19 million cases are left undiagnosed and untreated (White, 2012). An analysis of nationally representative, cross-sectional data indicate that hospitalized patients diagnosed with malnutrition tend to be older and sicker and also incur increased healthcare costs compared to non-malnourished patients (Corkins, 2014). A diagnosis of malnutrition has been associated with increased length-of-stay, readmissions, and risk of mortality in the hospital (Lew, 2016). An analysis of the 2010 HealthCare Cost and Utilization Project (HCUP), which provides a broad and nationally-representative dataset describing U.S. hospital discharges, reported that mortality was more than 5 times as common among patients with a malnutrition diagnosis (Corkins, 2014). Furthermore, malnutrition in hospitalized patients is also associated with higher post-operative complications such as infections and pressure ulcers (Fry, 2010; Banks, 2010). Early identification and subsequent intervention in particular can have a positive impact on those same patient outcomes (Somanchi, 2011). Additionally, documentation of malnutrition diagnoses has been associated with significant healthcare cost savings per hospital day per patient (Amaral, 2007). Lew CC, Yandell R, Fraser RJ, Chua AP, Chong MF, Miller M. Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. JPEN J Parenter Enteral Nutr. 2016. Corkins MR, Guenter P, Dimaria-ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186-95. White JV, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN. 2012;36(3):275–283. Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. J Parenter Enteral Nutr. 2011;35: 16-24. Somanchi et al., The Facilitated Early Enteral and Dietary Management Effectiveness Trial in Hospitalized Patients with Malnutrition. JPEN J Parenteral Enteral Nutr 2011 35:209. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Nutrition. 2010;26(9):896-901. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2):148-51. Amaral TF, Matos LC, Tavares MM, Subtil A, Martins R, Nazaré M, et al. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr. 2007 Dec;26(6):778–84. Kruizenga HM et al., Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. AM J Clin Nutrition. 2005 Nov 82(5): 1082-9.

Measure Specifications




Communication about Pain During the Hospital Stay (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-263)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
In response to concerns expressed by physicians, hospitals and others about the current Pain Management items on the HCAHPS Survey, CMS is considering new survey items for the HCAHPS Survey that focus on patients’ communication about pain with hospital staff. These items would replace the 3 Pain Management items on the HCAHPS Survey, which comprise the current Pain Management measure. CMS is currently evaluating data on the items as well as focus groups and interviews about the new pain items. A measure based on these items would be similar to the Pain Management composite measure currently used, which is based on the current HCAHPS Survey items The new measure, Communication about Pain During the Hospital Stay, focusses on communication about pain during the patient’s hospital stay, rather than on how well pain was controlled Different from the other measures in the HCAHPS Survey, this new measure uniquely focusses on communication about pain during the patient’s hospital stay The Communication about Pain During the Hospital Stay measure would replace the current Pain Management measure in the HCAHPS Survey, which is part of the IQR Program.  CMS is testing this new measure in a large-scale HCAHPS mode experiment.  CMS is currently collecting data for the Communication about Pain During the Hospital Stay measure from discharged patients at 50 hospitals that participated in the HCAHPS mode experiment, January-March 2016.

Measure Specifications




Completion of a Malnutrition Screening within 24 Hours of Admission (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-294)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The peer reviewed evidence supporting this measure is centered on the concept that malnutrition screening is an important first step in identifying malnutrition risk. Identifying patients at-risk of malnutrition allows clinicians to then complete a nutrition assessment that can confirm malnutrition and initiate a care plan recommending appropriate interventions. The evidence supports rapid recognition and treatment (as well as prevention) of malnutrition which is associated with lower costs of care, lower readmission rates, length of stay and hospital-acquired conditions. Malnutrition risk identified in patients through a malnutrition screening was able to predict certain patient outcomes including length of stay, mortality, and post-operative complications. (Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. J Parenter Enteral Nutr. 2011;35: 16-24.) Retrospective analysis of administrative data for years 2013 and 2014 from a university hospital, in which being nutritionally 'at-risk' was defined as a Nutritional risk screening-2002 score = 3, reinforces the association between risk of malnutrition and rates of mortality, as well as cost of care. After multivariate adjustment, 'at-risk' patients had a 3.7-fold (95% confidence interval: 1.91; 7.03) higher in-hospital mortality and higher costs (excess 5642.25 ± 1479.80 CHF in 2013 and 5529.52 ± 847.02 CHF in 2014, p < 0.001) than 'not at-risk' patients, while no difference was found for LOS. It also indicates that being nutritionally 'at-risk' affects three in every five patients. (Khalatbari-soltani S, Marques-vidal P. Impact of nutritional risk screening in hospitalized patients on management, outcome and costs: A retrospective study. Clin Nutr. 2016; pii: S0261-5614(16)00069-8.) 543 patients were recruited from consecutive admissions at 2 hyperacute stroke units in London and were screened for risk of malnutrition (low, medium, and high) according to MUST. Six-month outcomes were obtained for each patient through a national database. Results of the study among stroke patients showed a highly significant increase in mortality with increasing risk of malnutrition (P?Measure Specifications




Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 Hours of a Malnutrition Screening (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-296)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The peer reviewed evidence supporting this measure supports the assessment of patients at-risk of malnutrition via the completion of a nutrition assessment that can confirm malnutrition and initiate a care plan recommending appropriate interventions. The evidence supports rapid recognition and treatment (as well as prevention) of malnutrition which is associated with lower costs of care, lower readmission rates, length of stay and hospital-acquired conditions. Nutrition assessments conducted for at-risk patients identified by malnutrition screening using a validated screening tool was associated with key patient outcomes including less weight loss, reduced length of stay, improved muscle function, better nutritional intake, and fewer readmissions. (Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. J Parenter Enteral Nutr. 2011;35: 16-24.) A systematic review found that patient outcomes associated with malnutrition that was first identified by the use of a nutrition assessment was independently associated with poorer patient outcomes. Malnutrition was identified using two different assessment tools, the Subjective Global Assessment (SGA), this patient cohort was associated with higher hospital mortality, higher incidence of infection, and an increased risk of readmission. Using the Mini Nutritional Assessment (MNA), those identified as malnourished also experienced increased risk of postoperative complications. Additionally, fewer malnourished patients are discharged to their own homes compared to well-nourished patients. (Lew CC, Yandell R, Fraser RJ, Chua AP, Chong MF, Miller M. Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. JPEN. Journal of parenteral and enteral nutrition. 2016.) A prospective, matched case control study supports statistically significant associations of malnutrition (assessed using the Subjective Global Assessment) with increased lengths of stay, mortality, and hospitalization costs. Malnourished patients were also more likely to be readmitted within 15 days. (Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345-50.)

Measure Specifications




Follow-Up After Hospitalization for Mental Illness (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-165)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
This measure assesses whether health plan members who were hospitalized for a mental illness received timely follow-up visits. Studies suggest that patients who start treatment soon after diagnosis are less likely to have negative health and social outcomes. A plan’s ability to improve its seven- and 30-day follow-up rates may result in better overall health outcomes. As studies have shown, efforts to facilitate treatment following a hospital discharge also lead to less attrition in the initial period of treatment. Thus, this time period may be an important opportunity for health plans to implement strategies aimed at establishing strong relationships with mental health providers and facilitate long-term engagement in treatment. Low-intensity interventions that can be applied widely are typically implemented at periods of high risk for treatment dropout, such as following an emergency room or hospital discharge or the time of entry into outpatient treatment (Kreyenbuhl 2009). Emerging evidence suggests that brief, low-intensity case management interventions are effective in bridging the gap between inpatient and outpatient treatment (Dixon 2009). For example, Boyer et al evaluated strategies aimed at increasing attendance at outpatient appointments following hospital discharge. They found that the most common factor in a patient’s medical history that was linked to a patient having a follow-up visit was a discussion about the discharge plan between the inpatient staff and outpatient clinicians. Other strategies they found that increased attendance at appointments included having the patient meet with outpatient staff and visit the outpatient program prior to discharge (Boyer 2000). Although rates vary across studies, reviews of the literature suggest that up to one-third of individuals with serious mental illnesses who have had some contact with the mental health service system disengage from care. Younger age, male gender, ethnic minority background, and low social functioning have been consistently associated with disengagement from mental health treatment. Individuals with co-occurring psychiatric and substance use disorders, as well as those with early onset psychosis, are at particularly high risk of treatment dropout. Studies suggest that engagement strategies that specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment, can improve outcomes (Kreyenbuhl 2009).

Measure Specifications

Summary of NQF Endorsement Review




Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-262)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The goal of this measure of informed consent document quality is to support national strategies to promote patient-centered decision making. In evaluating hospitals' informed consent document quality, CMS seeks to increase the attention and effort that hospitals dedicate to providing high-quality informed consent, thereby supporting patient autonomy. This measure evaluates the quality of informed consent documents using items, developed through a consensus process, that are firmly based in the ethical and legal principles of informed consent, and are supported by patients as being meaningful improvements to the informed consent process. The measure aims to transform the informed consent document from a transactional form used to attain a patients’ signature to a meaningful document and resource that supports patients in the decision-making process. This informed consent document measure is a first step towards improving the practice of informed consent through quality measurement, and may compliment or serve as a platform for other measures of high-quality, patient-centered decision making. There are significant gaps in informed consent document quality and highly variable compliance with informed consent guidelines.[1-3] Hospitals often follow legal precedent, which results in perfunctory consent documents that convey the minimum amount of information necessary for compliance without providing patient-centered information that fosters patient autonomy or choice.[4-8] Prior studies, lawsuits and patient testimonies reflect a process that is broken, void of meaningful information for patients to develop informed preferences, and sometimes jeopardizing patient safety.[4,9-10] The implementation of a new quality measure that establishes a consistent and patient-centered standard based on existing guidelines for informed consent can lead to improved patient autonomy, patient safety, and high-quality decision making. The goal of this measure focuses on supporting the national efforts of CMS and NQF to improve patient-centered care and to fill several quality gaps in both the informed consent document and the measurement of these documents. References: 1. Bottrell MM, Alpert H, Fischbach RL, Emanuel LL. Hospital informed consent for procedure forms: facilitating quality patient-physician interaction. Archives of surgery (Chicago, Ill. : 1960). 2000;135(1):26-33. 2. Falagas ME, Korbila IP, Giannopoulou KP, Kondilis BK, Peppas G. Informed consent: how much and what do patients understand? American journal of surgery. 2009;198(3):420-435. 3. O'Neill O. Some limits of informed consent. Journal of medical ethics. 2003;29(1):4-7. 4. Oster, RR. Questioning Protocol, a Family's Perspective. Available at: http://www.engagingpatients.org/redesigning-the-care-experience/questioning-protocol-familys-perspective/. Accessed: July 5, 2015. 5. Habiba M, Jackson C, Akkad A, Kenyon S, Dixon-Woods M. Women's accounts of consenting to surgery: is consent a quality problem? Quality & safety in health care. 2004;13(6):422-427. 6. Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. Journal of the American College of Surgeons. 2009;208(4):627-634. 7. Mulley A, Trimble C, Elwyn G. Patients' preferences matter: stop the silent misdiagnosis. Bmj. 2012. 8. Krumholz HM, Schwartz J, Eddy E, et al. Surveillance Report: New Measure Probe. Not published: Prepared for: Centers for Medicare & Medicaid Services; Prepared by: Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE); 2014. 9. Montgomery v Lanarkshire Health Board. In: Court TS, ed. UKSC 11. United Kingdom. 2015. Available at: https://www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_Judgment.pdf. Accessed: July 5, 2016. 10. Statements on Principles. Relation of the Surgeon to the Patient: Informed Consent: American College of Surgeons; 2008:1-12.

Measure Specifications




Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-372)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Patients who are malnourished while in the hospital have an increased risk of complications, readmissions, and length of stay, which is associated with a significant increase in costs. Malnutrition is also associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications (Corkins, 2014), (Barker et al., 2011), (Amaral, et al., 2007), (Kruizenga et al. 2005). Presence of malnutrition/weight loss in hospitalized older adult patients is associated with higher odds of post-operative complications (including infections such as MRSA, C. diff, surgical site infections, and pneumonia) and decubitus ulcers (Fry, 2011). Nutritional status and progress are often not adequately documented in the medical record. It can be difficult to tell when (or if) patients are consuming food and supplements. In addition, nutritional procedures and EHR-triggered care are often lacking in the hospital. Similarly, nutritional care plans and patient issues are poorly communicated to post-acute facilities and PCPs (Corkins, 2014). Nutrition support intervention in patients identified by screening and assessment as at risk for malnutrition or malnourished may improve clinical outcomes (Mueller, 2011). Two research studies associated early nutritional care after risk identification with improved outcomes such as reduced length of stay, reduction in risk of readmissions, and cost of care (Lew, 2016), (Meehan, 2016). A systematic review of 62 studies with 10,187 randomized participants reported evidence for the effectiveness of nutritional supplements containing protein and energy. Overall, the review demonstrated that nutrition supplementation provided a significant reduction in mortality (RR 0.79, 95% CI 0.64 – 0.97) when patients were originally identified as “undernourished” (another term for malnourished). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75-0.99) (Milne, 2009). A randomized controlled trial of 652 hospitalized, malnourished older adults over the age of 65 evaluated the use of a high-protein oral nutrition supplement for its impact on patient outcomes of non-elective readmission and mortality. The study found no effects towards improving 90-day readmission rate compared to placebo, but saw a significant reduction of 90-day mortality (p = 0.018) (Deutz, 2016). Finally, documentation of malnutrition diagnoses has been associated with significant healthcare cost savings per hospital day per patient (Amaral, 2007). Amaral TF, Matos LC, Tavares MM, Subtil A, Martins R, Nazaré M, et al. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr. 2007 Dec;26(6):778–84. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8(2):514-27. Corkins MR, Guenter P, Dimaria-ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186-95. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2):148-51. Kruizenga HM et al., Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. AM J Clin Nutrition. 2005 Nov 82(5): 1082-9. Lew CC, Yandell R, Fraser RJ, Chua AP, Chong MF, Miller M. Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. JPEN J Parenter Enteral Nutr. 2016. Meehan A, Loose C, Bell J, Partridge J, Nelson J, Goates S. Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs. J Nurs Care Qual. 2016. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;(2):CD003288. Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. JPEN J Parenter Enteral Nutr. 2011;35: 16-24. White JV, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275–283. Somanchi et al., The Facilitated Early Enteral and Dietary Management Effectiveness Trial in Hospitalized Patients with Malnutrition. JPEN J Parenteral Enteral Nutr 2011 35:209.

Measure Specifications




Patient Panel Smoking Prevalence IQR (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-068)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Cigarette smoking is still the leading preventable cause of death and disease in the U.S. and costs the U.S. health care system nearly $170 billion in direct medical care for adults each year (CDC 2014a; HHS 2014; Xu et al. 2014). Currently more than 16 million US residents are living with a smoking-related illness (HHS 2014). Smoking harms nearly every organ in the body and has been causally linked to numerous cancers, heart disease and stroke, chronic obstructive pulmonary disease, pneumonia, other respiratory diseases, aortic aneurysm, peripheral vascular disease, cataracts and blindness, age-related macular degeneration, periodontitis, diabetes, pregnancy and reproductive complications, bone fractures, arthritis, and reduced immune function (HHS, 2014). Mortality among current smokers is two to three times that of persons who never smoked (Jha et al. 2013). Since the first Surgeon General’s Report on Smoking and Health in 1964, cigarette smoking has killed more than 20 million people in the U.S. (HHS 2014). Between 2005-2009, 87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all coronary heart disease deaths were attributable to smoking and secondhand smoke exposure (HHS, 2014), making it an essential risk factor to address to reduce both disease burden and health care costs. The toll smoking takes on health extends beyond the smokers. Since 1964, almost 2.5 million nonsmoking adults have died from heart disease and lung cancer caused by exposure to secondhand smoke, and 100,000 babies have died of sudden infant death syndrome or complications from prematurity, low birth weight, or other conditions caused by parental smoking, particularly smoking by the mother (HHS, 2014). Reducing cigarette smoking in the community can impact the health and health care costs of nonsmokers as well. CDC (Centers for Disease Control and Prevention). (2014a). CDC’s Tips from Former Smokers campaign provided outstanding return on investment. Atlanta, GA. Available at: http://www.cdc.gov/media/releases/2014/p1210-tips-roi.html. (Accessed 27 October, 2015). HHS (US Department of Health and Human Services). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. (Accessed 23 September, 2015). Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. (2014) Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine, 48(3), p.326-333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603661/ (Accessed 24 September, 2015). Jha, P. and Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 2014(370), p.60-68. Available at: http://www.nejm.org/doi/full/10.1056/nejmra1308383. (Accessed 22 October, 2015). doi: 10.1056/NEJMra1308383

Measure Specifications




Safe Use of Opioids – Concurrent Prescribing (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-167)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Unintentional opioid overdose fatalities have become an epidemic in the last 20 years and a major public health concern in the United States (Rudd 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration. The U.S. Food and Drug Administration recently announced new requirements calling for class-wide changes to drug labeling, to help inform health care providers and patients of the serious risks associated with the combined use of certain opioid medications and benzodiazepines. Concurrent prescriptions of opioids or opioids and benzodiazepines puts patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell 2016). An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (NIDA 2011). Another analysis of more than 1 million hospital admissions in the United States found that over 43% of all patients with nonsurgical admissions were exposed to multiple opioids during their hospitalization (Herzig 2013). Studies of multiple claims and prescription databases have shown that between 5%-15% percent of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu 2013, Mack 2015, Park 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell 2016). Emergency Department (ED) visit rates involving both opioid analgesics and benzodiazepines increased from 11.0 in 2004 to 34.2 per 100,000 population in 2011 (Jones 2015). Adopting a measure that calculates the proportion of patients prescribed two or more different opioids or opioids and benzodiazepines concurrently, has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by 1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and 2) discouraging providers from prescribing two or more different opioids or opioids and benzodiazepines concurrently. References: Dasgupta, N., et al. "Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality", Pain Medicine, Wiley Periodicals, Inc., Sep 2015. http://onlinelibrary.wiley.com/doi/10.1111/pme.12907/abstract Dowell, D., Haegerich, T., Chou, R. "CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016". MMWR Recomm Rep 2016;65. http://www.cdc.gov/media/dpk/2016/dpk-opioid-prescription-guidelines.html Herzig, S., Rothberg, M., Cheung, M., et al. "Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals". Nov 2013. DOI: 10.1002/jhm.2102. http://onlinelibrary.wiley.com/doi/10.1002/jhm.2102/abstract Jena, A., et al. "Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims", BMJ 2014; 348:g1393 doi: 10.1136/bmj.g1393. http://www.bmj.com/content/348/bmj.g1393 Jones, CM., McAninch, JK. "Emergency Department Visits and Overdose Deaths From Combined Use of Opioids and Benzodiazepines". Am J Prev Med. 2015 Oct;49(4):493-501. doi: 10.1016/j.amepre.2015.03.040. Epub 2015 Jul 3. http://www.ncbi.nlm.nih.gov/pubmed/26143953 Liu, Y., Logan, J., Paulozzi, L., et al. "Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics". Am J Manag Care. 2013 Aug;19(8):648-65. http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n8/Potential-Misuse-and-Inappropriate-Prescription-Practices-Involving-Opioid-Analgesics/ Mack, K., Zhang, K., et al. "Prescription Practices involving Opioid Analgesics among Americans with Medicaid, 2010", J Health Care Poor Underserved. 2015 Feb; 26(1): 182-198. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365785/ National Institute on Drug Abuse. "Analysis of opioid prescription practices finds areas of concern". April 2011. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2011/04/analysis-opioid-prescription-practices-finds-areas-concern Park, T., et al. "Benzodiazepine Prescribing Patterns and Deaths from Drug Overdose among US Veterans Receiving Opioid Analgesics: Case-cohort Study", BMJ 2015; 350:h2698. http://www.bmj.com/content/350/bmj.h2698 Rudd, R., Aleshire, N., Zibbell, J., et al. "Increases in Drug and Opioid Overdose Deaths - United States, 2000-2014". MMWR, Jan 2016. 64(50);1378-82 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm U.S. Food and Drug Administration. “FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use”. Aug 31, 2016. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm518697.htm

Measure Specifications




Influenza Immunization (IMM-2) (Program: ; MUC ID: MUC16-053)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Up to 1 in 5 people in the United States get influenza every season (CDC Key Facts 2015). Each year an average of approximately 226,000 people in the US are hospitalized with complications from influenza and between 3,000 and 49,000 die from the disease and its complications (Thompson 2003). Combined with pneumonia, influenza is the nation's 8th leading cause of death (Heron 2012). Up to two-thirds of all deaths attributable to pneumonia and influenza occur in the population of patients that have been hospitalized during flu season regardless of age (Fedson 2000). The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza. Vaccination is associated with reductions in influenza among all age groups (Kostova 2013). The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older. References: Centers for Disease Control and Prevention. Key facts about influenza and the influenza vaccine, October 2015. Available at: http://www.cdc.gov/flu/keyfacts.htm. Accessed October 14, 2015. Fedson DS, Houck PM, Bratzler DW. Hospital-based influenza and pneumococcal vaccination: Sutton's Law applied to prevention. Infect Control Hosp Epi. 2000;21:692-699. Heron M. Deaths: Leading Causes for 2012. National Vital Statistics Reports; vol 64 no 10. Hyattsville, MD: National Center for Health Statistics. 2015. Kostova D, Reed C, Finelli L, Cheng P, Gargiullo PM, Shay DK, Singleton JA, Meltzer MI, Lu P,2 and Joseph S. Bresee1 Influenza Illness and Hospitalizations Averted by Influenza Vaccination in the United States, 2005-2011. PLoS One. 2013; 8(6): e66312 Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, Fukuda. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003 January 8; 289 (2): 179-186.

Measure Specifications




Tobacco Use Screening (TOB-1) (Program: ; MUC ID: MUC16-050)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 480,000 deaths each year (CDC MMWR 2014). Smoking is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer wound healing, and many other diseases (DHHS 2014). Tobacco use creates a heavy cost to society as well as to individuals. Smoking-attributable health care expenditures are estimated to be at least $130 billion per year in direct medical expenses for adults, and over $150 billion in lost productivity (DHHS 2014). There is strong and consistent evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the user's risk of suffering from tobacco-related disease and improve outcomes for those already suffering from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood 2003 and 1997; Rigotti 2012). Effective, evidence-based tobacco dependence interventions have been clearly identified and include brief clinician advice, individual, group, or telephone counseling, and use of FDA-approved medications. These treatments are clinically effective and extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco-free environment and because patients may be more motivated to quit as a result of their illness) offers an ideal opportunity to provide cessation assistance that may promote the patient's medical recovery. Patients who receive even brief advice and intervention from their care providers are more likely to quit than those who receive no intervention (DHHS, 2008). References: Baumeister SE, Schumann A, Meyer C, et al. Effects of smoking cessation on health care use: is elevated risk of hospitalization among former smokers attributable to smoking-related morbidity? Drug Alcohol Depend. 2007 May 11;88(2-3):197-203. Epub 2006 Nov 21. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults — United States, 2005–2013. Morbidity and Mortality Weekly Report (MMWR) 2014. 63(47); 1108-1112. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a4.htm?s_cid=mm6347a4_w Lightwood JM. The economics of smoking and cardiovascular disease. Prog Cardiovasc Dis. 2003 Jul-Aug;46(1):39-78. Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation. 1997 Aug 19;96 (4):1089-96. Rigotti, et al. Interventions for smoking cessation in hospitalized patients. Cochrane Database of Systematic Reviews. 2012. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001837.pub3/abstract U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf U.S. Department of Health and Human Services. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD, U.S. Department of Health and Human Services; 2008 May. Available from: http://www.ncbi.nlm.nih.gov/books/NBK63952/

Measure Specifications




Tobacco Use Treatment Provided or Offered (TOB-2)/Tobacco Use Treatment (TOB-2a) (Program: ; MUC ID: MUC16-051)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 480,000 deaths each year (CDC MMWR 2014). Smoking is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer wound healing, and many other diseases (DHHS 2014). Tobacco use creates a heavy cost to society as well as to individuals. Smoking-attributable health care expenditures are estimated to be at least $130 billion per year in direct medical expenses for adults, and over $150 billion in lost productivity (DHHS 2014). There is strong and consistent evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the user's risk of suffering from tobacco-related disease and improve outcomes for those already suffering from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood 2003 and 1997; Rigotti 2012). Effective, evidence-based tobacco dependence interventions have been clearly identified and include brief clinician advice, individual, group, or telephone counseling, and use of FDA-approved medications. These treatments are clinically effective and extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco-free environment and because patients may be more motivated to quit as a result of their illness) offers an ideal opportunity to provide cessation assistance that may promote the patient's medical recovery. Patients who receive even brief advice and intervention from their care providers are more likely to quit than those who receive no intervention (DHHS, 2008). References: Baumeister SE, Schumann A, Meyer C, et al. Effects of smoking cessation on health care use: is elevated risk of hospitalization among former smokers attributable to smoking-related morbidity? Drug Alcohol Depend. 2007 May 11;88(2-3):197-203. Epub 2006 Nov 21. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults — United States, 2005–2013. Morbidity and Mortality Weekly Report (MMWR) 2014. 63(47); 1108-1112. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a4.htm?s_cid=mm6347a4_w Lightwood JM. The economics of smoking and cardiovascular disease. Prog Cardiovasc Dis. 2003 Jul-Aug;46(1):39-78. Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation. 1997 Aug 19;96 (4):1089-96. Rigotti, et al. Interventions for smoking cessation in hospitalized patients. Cochrane Database of Systematic Reviews. 2012. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001837.pub3/abstract U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf U.S. Department of Health and Human Services. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD, U.S. Department of Health and Human Services; 2008 May. Available from: http://www.ncbi.nlm.nih.gov/books/NBK63952/

Measure Specifications




Tobacco Use Treatment Provided or Offered at Discharge (TOB-3)/Tobacco Use Treatment at Discharge (TOB-3a) (Program: ; MUC ID: MUC16-052)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 480,000 deaths each year (CDC MMWR 2014). Smoking is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer wound healing, and many other diseases (DHHS 2014). Tobacco use creates a heavy cost to society as well as to individuals. Smoking-attributable health care expenditures are estimated to be at least $130 billion per year in direct medical expenses for adults, and over $150 billion in lost productivity (DHHS 2014). There is strong and consistent evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the user's risk of suffering from tobacco-related disease and improve outcomes for those already suffering from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood 2003 and 1997; Rigotti 2012). Effective, evidence-based tobacco dependence interventions have been clearly identified and include brief clinician advice, individual, group, or telephone counseling, and use of FDA-approved medications. These treatments are clinically effective and extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco-free environment and because patients may be more motivated to quit as a result of their illness) offers an ideal opportunity to provide cessation assistance that may promote the patient's medical recovery. Patients who receive even brief advice and intervention from their care providers are more likely to quit than those who receive no intervention (DHHS, 2008). References: Baumeister, S. E., Schumann, A., Meyer, C., John, U., Volzke, H., & Alte, D. (2007). Effects of smoking cessation on health care use: Is elevated risk of hospitalization among former smokers attributable to smoking-related morbidity? Drug and Alcohol Dependence, 88(2–3), 197–203. Centers for Disease Control and Prevention. (2014). Current cigarette smoking among adults—United States, 2005–2013. Morbidity and Mortality Weekly Report (MMWR), 63(47), 1108–1112. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a4.htm?s_cid=mm6347a4_w. Lightwood, J. M. (2003). The economics of smoking and cardiovascular disease. Progress in Cardiovascular Diseases, 46(1), 39–78. Lightwood, J. M., & Glantz, S. A. (1997). Short-term economic and health benefits of smoking cessation: Myocardial infarction and stroke. Circulation, 96(4), 1089–1096. Rigotti, N. A., Clair, C., Munafo, M. R., & Stead, L. F. (2012). Interventions for smoking cessation in hospitalized patients. Cochrane Database of Systematic Reviews. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001837.pub3/abstract. U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf U.S. Department of Health and Human Services. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD, U.S. Department of Health and Human Services; 2008 May. Available from: http://www.ncbi.nlm.nih.gov/books/NBK63952/

Measure Specifications




Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting (Program: ; MUC ID: MUC16-041)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Hospitalized patients are at risk for delirium, or "acute confusional state," which is a common clinical syndrome that is associated with increased mortality in ICU patients as well as the advancement of cognitive impairment. Antipsychotics are often used off-label as a method of treating patients in an acute confusional state despite conflicting evidence regarding the effectiveness of antipsychotics in treating these disorders. Clinical guidelines recommend against using antipsychotics as a standard first line of treatment for patients experiencing aggressive behavior unless they present a threat to themselves or their caregivers. References: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. Oct 2015 ;63:2227-2246; 2015. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. The American journal of psychiatry. May 1999;156(5 Suppl):1-20. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. Jan 2013;41(1):263-306. Barr J, Pandharipande PP. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion. Crit Care Med. Sep 2013;41(9 Suppl 1):S99-115. Campbell N, Boustani MA, Ayub A, et al. Pharmacological management of delirium in hospitalized adults--a systematic evidence review. Journal of general internal medicine. Jul 2009;24(7):848-853. Flaherty JH, Gonzales JP, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. Journal of the American Geriatrics Society. Nov 2011;59 Suppl 2:S269-276. NICE (National Institute for Health and Clinical Excellence) Dementia: Supporting people with dementia and their careers in health and social care. 2015 (Issued November 2006, Modified March 2015). Rooney S, Qadir M, Adamis D, McCarthy G. Diagnostic and treatment practices of delirium in a general hospital. Aging Clin Exp Res. Dec 2014;26(6):625-633. Sampson EL, White N, Leurent B, et al. Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study. The British journal of psychiatry: the journal of mental science. Sep 2014;205(3):189-196. Sampson EL, White N, Lord K, et al. Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study. Pain. Apr 2015;156(4):675-683. Tjia J, Briesacher BA, Peterson D, Liu Q, Andrade SE, Mitchell SL. Use of medications of questionable benefit in advanced dementia. JAMA internal medicine. Nov 2014;174(11):1763-1771.

Measure Specifications




Median Time from ED Arrival to ED Departure for Discharged ED Patients (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-055)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. According to a 2002 national U.S. survey, more than 90 percent of large hospitals report EDs operating "at" or "over" capacity. Overcrowding and heavy emergency resource demand have led to a number of problems, including ambulance refusals, prolonged patient waiting times, increased suffering for those who wait, rushed and unpleasant treatment environments, and potentially poor patient outcomes. Approximately one third of hospitals in the U.S. report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the ED. In a recent national survey, 40 percent of hospital leaders viewed ED crowding as a symptom of workforce shortages. ED crowding may result in delays in the administration of medication such as antibiotics for pneumonia and has been associated with perceptions of compromised emergency care. For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised. References: Derlet RW, Richards JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J. 2002;95:846-9. Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000; 35:63-8. Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J. 2003; 20:406-9. Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006; 54:270-5. Pines JM, et al. ED crowding is associated with variable perceptions of care compromise. Acad Emerg Med. 2007;14:1176-81. Pines JM, et al. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:6-7. Schull MJ, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577-85. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-5. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Cutrona SL, Bor DH, Himmelstein DU. Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health Aff (Millwood). 2008;27:w84-95.

Measure Specifications




Median Time to Pain Management for Long Bone Fracture (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-056)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pain management in patients with long bone fractures is undertreated in emergency departments (Ritsema et al., 2007). Emergency department pain management has room for improvement (Ritsema et al., 2007). Patients with bone fractures continue to lack administration of pain medication as part of treatment regimens (Brown et al., 2003). When performance measures are implemented for pain management of these patients administration and treatment rates for pain improve (Herr & Titler, 2009). Disparities continue to exist in the administration of pain medication for minorities (Epps, Ware, & Packard, 2008; Todd, Samaroo, & Hoffman, 1993) and children as well (Brown et al., 2003; Friedland & Kulick, 1994). References: Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003 Aug;42(2):197-205. Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 9.0a. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2016 Jan 1. various p. Epps CD, Ware LJ, Packard A. Ethnic wait time differences in analgesic administration in the emergency department. Pain Manag Nurs. 2008 Mar;9(1):26-32. Friedland LR, Kulick RM. Emergency department analgesic use in pediatric trauma victims with fractures. Ann Emerg Med. 1994 Feb;23(2):203-7. Herr K, Titler M. Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends. J Emerg Nurs. 2009 Jul;35(4):312-20. Ritsema TS, Kelen GD, Pronovost PJ, Pham JC. The national trend in quality of emergency department pain management for long bone fractures. Acad Emerg Med. 2007 Feb;14(2):163-9. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993 Mar 24-31;269(12):1537-9.

Measure Specifications

Summary of NQF Endorsement Review




Safe Use of Opioids – Concurrent Prescribing (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-167)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Unintentional opioid overdose fatalities have become an epidemic in the last 20 years and a major public health concern in the United States (Rudd 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration. The U.S. Food and Drug Administration recently announced new requirements calling for class-wide changes to drug labeling, to help inform health care providers and patients of the serious risks associated with the combined use of certain opioid medications and benzodiazepines. Concurrent prescriptions of opioids or opioids and benzodiazepines puts patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell 2016). An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (NIDA 2011). Another analysis of more than 1 million hospital admissions in the United States found that over 43% of all patients with nonsurgical admissions were exposed to multiple opioids during their hospitalization (Herzig 2013). Studies of multiple claims and prescription databases have shown that between 5%-15% percent of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu 2013, Mack 2015, Park 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell 2016). Emergency Department (ED) visit rates involving both opioid analgesics and benzodiazepines increased from 11.0 in 2004 to 34.2 per 100,000 population in 2011 (Jones 2015). Adopting a measure that calculates the proportion of patients prescribed two or more different opioids or opioids and benzodiazepines concurrently, has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by 1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and 2) discouraging providers from prescribing two or more different opioids or opioids and benzodiazepines concurrently. References: Dasgupta, N., et al. "Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality", Pain Medicine, Wiley Periodicals, Inc., Sep 2015. http://onlinelibrary.wiley.com/doi/10.1111/pme.12907/abstract Dowell, D., Haegerich, T., Chou, R. "CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016". MMWR Recomm Rep 2016;65. http://www.cdc.gov/media/dpk/2016/dpk-opioid-prescription-guidelines.html Herzig, S., Rothberg, M., Cheung, M., et al. "Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals". Nov 2013. DOI: 10.1002/jhm.2102. http://onlinelibrary.wiley.com/doi/10.1002/jhm.2102/abstract Jena, A., et al. "Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims", BMJ 2014; 348:g1393 doi: 10.1136/bmj.g1393. http://www.bmj.com/content/348/bmj.g1393 Jones, CM., McAninch, JK. "Emergency Department Visits and Overdose Deaths From Combined Use of Opioids and Benzodiazepines". Am J Prev Med. 2015 Oct;49(4):493-501. doi: 10.1016/j.amepre.2015.03.040. Epub 2015 Jul 3. http://www.ncbi.nlm.nih.gov/pubmed/26143953 Liu, Y., Logan, J., Paulozzi, L., et al. "Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics". Am J Manag Care. 2013 Aug;19(8):648-65. http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n8/Potential-Misuse-and-Inappropriate-Prescription-Practices-Involving-Opioid-Analgesics/ Mack, K., Zhang, K., et al. "Prescription Practices involving Opioid Analgesics among Americans with Medicaid, 2010", J Health Care Poor Underserved. 2015 Feb; 26(1): 182-198. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365785/ National Institute on Drug Abuse. "Analysis of opioid prescription practices finds areas of concern". April 2011. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2011/04/analysis-opioid-prescription-practices-finds-areas-concern Park, T., et al. "Benzodiazepine Prescribing Patterns and Deaths from Drug Overdose among US Veterans Receiving Opioid Analgesics: Case-cohort Study", BMJ 2015; 350:h2698. http://www.bmj.com/content/350/bmj.h2698 Rudd, R., Aleshire, N., Zibbell, J., et al. "Increases in Drug and Opioid Overdose Deaths - United States, 2000-2014". MMWR, Jan 2016. 64(50);1378-82 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm U.S. Food and Drug Administration. “FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use”. Aug 31, 2016. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm518697.htm

Measure Specifications




CAHPS Hospice Survey: Getting Emotional and Spiritual Support (Program: Hospice Quality Reporting Program; MUC ID: MUC16-037)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Getting Help for Symptoms (Program: Hospice Quality Reporting Program; MUC ID: MUC16-039)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Getting Hospice Care Training (Program: Hospice Quality Reporting Program; MUC ID: MUC16-035)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Getting Timely Care (Program: Hospice Quality Reporting Program; MUC ID: MUC16-036)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Hospice Team Communications (Program: Hospice Quality Reporting Program; MUC ID: MUC16-032)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Rating of Hospice (Program: Hospice Quality Reporting Program; MUC ID: MUC16-031)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Treating Family Member with Respect (Program: Hospice Quality Reporting Program; MUC ID: MUC16-040)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




CAHPS Hospice Survey: Willingness to Recommend (Program: Hospice Quality Reporting Program; MUC ID: MUC16-033)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Measure Specifications

Summary of NQF Endorsement Review




Communication about Pain During the Hospital Stay (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC16-263)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
In response to concerns expressed by physicians, hospitals and others about the current Pain Management items on the HCAHPS Survey, CMS is considering new survey items for the HCAHPS Survey that focus on patients’ communication about pain with hospital staff. These items would replace the 3 Pain Management items on the HCAHPS Survey, which comprise the current Pain Management measure. CMS is currently evaluating data on the items as well as focus groups and interviews about the new pain items. A measure based on these items would be similar to the Pain Management composite measure currently used, which is based on the current HCAHPS Survey items The new measure, Communication about Pain During the Hospital Stay, focusses on communication about pain during the patient’s hospital stay, rather than on how well pain was controlled Different from the other measures in the HCAHPS Survey, this new measure uniquely focusses on communication about pain during the patient’s hospital stay The Communication about Pain During the Hospital Stay measure would replace the current Pain Management measure in the HCAHPS Survey, which is part of the IQR Program.  CMS is testing this new measure in a large-scale HCAHPS mode experiment.  CMS is currently collecting data for the Communication about Pain During the Hospital Stay measure from discharged patients at 50 hospitals that participated in the HCAHPS mode experiment, January-March 2016.

Measure Specifications




Identification of Opioid Use Disorder (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC16-428)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Opioid use disorder and opioid overdose are latent risks with the use of opioid medications. These adverse drug events (ADE) are potentially preventable and current policy and literature has made a call to make a continuous effort to reduce morbidity and mortality secondary to opioids, which has achieved epidemic levels.[1-4] Opioid related ADEs including opioid use disorder (OUD) have led to an increase of deaths. Between 1999 to 2014, more than 165,000 persons died from overdose related to opioid use in the United States.[5, 6] Monitoring for any indicators of substance use allows clinicians to prevent or treat OUD and prevent related ADEs. The Diagnostic and Statistical Manual of Mental Disorders noted that “routine urine toxicology test results are often positive for opioid drugs in individuals with opioid use disorder.”[7] Urine drug testing has been consistently recommended by clinical guidelines for monitoring patients on opioid therapy and regarded as a useful marker for evaluating compliance to the therapy and detecting the misuse of prescribed medications or use of illicit agents.[1, 8, 9] Studies have suggested that results from the urine drug testing are informative in making clinical assessment on aberrant drug-taking behaviors and determining the need for clinical referral to specialists.[10, 11] Monitoring adherence to the plan of care is also recommended by guidelines to ensure the effectiveness and safety of the prescribed treatment.[1, 7] The prescription drug monitoring program (PDMP) is a central data repository that collects statewide data on the controlled substance prescriptions and can be a useful tool to monitor prescription drug utilization.[12] Citations: 1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain. MMWR Recomm Rep 2016;65(1):1-49. Available at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. 2. Liu Y, Logan JE, Paulozzi LJ, Zhang K, Jones CM. Potential misuse and inappropriate prescription practices involving opioid analgesics. Am J Manag Care. 2013;19(8):648-65. 3. Mack KA, Zhang K, Paulozzi L, Jones C. Prescription practices involving opioid analgesics among Americans with Medicaid, 2010. J Health Care Poor Underserved. 2015;26(1):182-98. 4. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-21. 5. Centers for Disease Control and Prevention (CDC). Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at: http://wonder.cdc.gov/mcd.html. 6. Frenk SM, Porter KS, Paulozzi LJ. Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS data brief, no 189. Hyattsville, MD: National Center for Health Statistics. 2015. 7. American Psychiatric Association. Substance use disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association; 2013. 8. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130. 9. Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123-143. 10. Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1096-1102. 11. Gilbert JW, Wheeler GR, Mick GE, et al. Urine drug testing in the treatment of chronic noncancer pain in a Kentucky private neuroscience practice: the potential effect of Medicare benefit changes in Kentucky. Pain Physician. 2010;13:187-194. 12. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012;15:eS67-ES92.

Measure Specifications




Medication Continuation following Inpatient Psychiatric Discharge (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC16-048)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The medications that constitute the numerator are evidence-based with demonstrated efficacy and safety for MDD, schizophrenia, and bipolar disorder. The continued use of effective medication is implicit and underscored by a 2010 meta-analysis of 54 double-blind placebo-controlled relapse prevention studies which found that, among patients with depression who initially responded to drug therapy, continuation of antidepressants significantly reduced relapse (odds ratios 0.35; 95% CI 0.32–0.39), and this reduction was not affected by patient age, drug class, depression subtype, or treatment duration (Glue, Donovan, Kolluri, Emir, 2010). Furthermore, among patients with bipolar disorder, medication adherence was significantly associated with the course of illness (Sylvia, 2014). Among patients with schizophrenia, those who were “good compliers” according to the Medication Adherence Rating Scale had better outcomes in terms of rehospitalization rates and medication maintenance (Jaeger, Pfiffner, Weiser, et al., 2012). A review of the medication adherence literature found that as patient medication adherence increases, the average annual healthcare spending levels decrease (Braithwaite, Shirkhorshidian, Jones, Johnsrud, 2013; Roebuck, Liberman, Gemmill-Toyama, Brennan, 2011). This measure focuses on medication continuation rather than adherence because IPFs can implement a variety of processes to improve medication continuation during the transition from inpatient to outpatient care. Examples that have been shown to increase medication compliance and prevent negative outcomes associated with nonadherence include patient education, enhanced therapeutic relationships, shared decision-making, and text-message reminders, with emphasis on multidimensional approaches (Douaihy, Kelly, Sullivan, 2013; Haddad, Brain, Scott, 2014; Hung, 2014; Kasckow and Zisook, 2008; Lanouette, Folsom, Sciolla, Jeste, 2009; Mitchell, 2007; Sylvia, Hay, Ostacher, et al., 2013). Citations: * Braithwaite, S., Shirkhorshidian, I., Jones, K., & Johnsrud, M. (2013). The role of medication adherence in the US healthcare system. Retrieved from http://avalere.com/research/docs/20130612_NACDS_Medication_Adherence.pdf * Douaihy, A. B., Kelly, T. M., & Sullivan, C. (2013). Medications for substance use disorders. Soc Work Public Health, 28(3-4), 264-278. doi: 10.1080/19371918.2013.759031 * Glue, P., Donovan, M. R., Kolluri, S., & Emir, B. (2010). Meta-analysis of relapse prevention antidepressant trials in depressive disorders. Australian and New Zealand Journal of Psychiatry, 44(8), 697-705. doi: 10.3109/00048671003705441 * Haddad, P. M., Brain, C., & Scott, J. (2014). Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies. Patient Relat Outcome Meas, 5, 43-62. doi: 10.2147/PROM.S42735 * Jaeger, S., Pfiffner, C., Weiser, P., Kilian, R., Becker, T., Langle, G., . . . Steinert, T. (2012). Adherence styles of schizophrenia patients identified by a latent class analysis of the Medication Adherence Rating Scale (MARS): a six-month follow-up study. Psychiatry Research, 200(2-3), 83-88. doi: 10.1016/j.psychres.2012.03.033 * Kasckow, J. W., & Zisook, S. (2008). Co-occurring depressive symptoms in the older patient with schizophrenia. Drugs and Aging, 25(8), 631-647. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18665657 * Lanouette, N. M., Folsom, D. P., Sciolla, A., & Jeste, D. V. (2009). Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review. Psychiatric Services, 60(2), 157-174. doi: 10.1176/appi.ps.60.2.157 * Roebuck, M. C., Liberman, J. N., Gemmill-Toyama, M., & Brennan, T. A. (2011). Medication adherence leads to lower health care use and costs despite increased drug spending. Health Affairs, 30(1), 91-99. doi: 10.1377/hlthaff.2009.1087 * Sylvia, L. G., Hay, A., Ostacher, M. J., Miklowitz, D. J., Nierenberg, A. A., Thase, M. E., . . . Perlis, R. H. (2013). Association between therapeutic alliance, care satisfaction, and pharmacological adherence in bipolar disorder. Journal of Clinical Psychopharmacology, 33(3), 343-350. doi: 10.1097/JCP.0b013e3182900c6f * Sylvia, L. G., Reilly-Harrington, N. A., Leon, A. C., Kansky, C. I., Calabrese, J. R., Bowden, C. L., . . . Nierenberg, A. A. (2014). Medication adherence in a comparative effectiveness trial for bipolar disorder. Acta Psychiatrica Scandinavica, 129(5), 359-365. doi: 10.1111/acps.12202

Measure Specifications




Medication Reconciliation at Admission (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC16-049)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
A systematic review published in 2012 examined 26 controlled studies related to hospital-based medication reconciliation practices (Mueller, Sponsler, Kripalani, Schnipper, 2012). The studies “consistently demonstrated a reduction in medication discrepancies (17/17 studies), potential adverse drug events (5/6 studies), and adverse drug events (2/3 studies).” Of the 26 studies identified, six were rated as good quality; five as fair; and 15 as poor, using the United States Preventive Services Task Force (USPSTF) criteria. Although the heterogeneity of the study designs makes it difficult to identify the key elements of successful interventions, accurate pre-admission medication lists are critical to the medication reconciliation process as identified in the studies. Pre-admission medication reconciliation is further supported by two recent studies (MATCH and MARQUIS), which noted that most of the medication discrepancies or potential adverse drug events identified were the result of errors in obtaining the medication history (Gleason, McDaniel, Feinglass, et al., 2010; Salanitro, Kripalani, Resnic, et al., 2013). Five of the elements proposed by this measure concept are aligned with interventions from MATCH, MARQUIS, and the Joint Commission (2015). Specific to the IPF, a study indicated that 48% of patients had = 1 errors in their medication history and that the rate of ADEs is one-third higher in IPFs than in acute care hospitals (Cornish, Knowles, Marchesano, et al., 2005). Citations: * Cornish, P. L., Knowles, S. R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D. N., & Etchells, E. E. (2005). Unintended medication discrepancies at the time of hospital admission. Archives of Internal Medicine, 165(4), 424-429. doi:10.1001/archinte.165.4.424 * Gleason, K. M., McDaniel, M. R., Feinglass, J., Baker, D. W., Lindquist, L., Liss, D., & Noskin, G. A. (2010). Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. Journal of General Internal Medicine, 25(5), 441-447. doi:10.1007/s11606-010-1256-6 * Mueller, S. K., Sponsler, K. C., Kripalani, S., & Schnipper, J. L. (2012). Hospital-based medication reconciliation practices: a systematic review. Archives of Internal Medicine, 172(14), 1057-1069. doi: 10.1001/archinternmed.2012.2246 * Salanitro, A. H., Kripalani, S., Resnic, J., Mueller, S. K., Wetterneck, T. B., Haynes, K. T., . . . Schnipper, J. L. (2013). Rationale and design of the Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS). BMC Health Services Research, 13, 230. doi:10.1186/1472-6963-13-230 * The Joint Commission. (2015). National Patient Safety Goals Effective January 1, 2015: Hospital Accreditation Program. Retrieved from http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf

Measure Specifications




Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-143)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Measure Specifications

Summary of NQF Endorsement Review




Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-319)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications




Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-325)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications




Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-144)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Measure Specifications

Summary of NQF Endorsement Review




Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-321)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications




Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-327)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications




Adult Local Current Smoking Prevalence (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-069)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Cigarette smoking is still the leading preventable cause of death and disease in the U.S. and costs the U.S. health care system nearly $170 billion in direct medical care for adults each year (CDC 2014a; HHS 2014; Xu et al. 2014). Currently more than 16 million US residents are living with a smoking-related illness (HHS 2014). Smoking harms nearly every organ in the body and has been causally linked to numerous cancers, heart disease and stroke, chronic obstructive pulmonary disease, pneumonia, other respiratory diseases, aortic aneurysm, peripheral vascular disease, cataracts and blindness, age-related macular degeneration, periodontitis, diabetes, pregnancy and reproductive complications, bone fractures, arthritis, and reduced immune function (HHS, 2014). Mortality among current smokers is two to three times that of persons who never smoked (Jha et al. 2013). Since the first Surgeon General’s Report on Smoking and Health in 1964, cigarette smoking has killed more than 20 million people in the U.S. (HHS 2014). Between 2005-2009, 87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all coronary heart disease deaths were attributable to smoking and secondhand smoke exposure (HHS, 2014), making it an essential risk factor to address to reduce both disease burden and health care costs. The toll smoking takes on health extends beyond the smokers. Since 1964, almost 2.5 million nonsmoking adults have died from heart disease and lung cancer caused by exposure to secondhand smoke, and 100,000 babies have died of sudden infant death syndrome or complications from prematurity, low birth weight, or other conditions caused by parental smoking, particularly smoking by the mother (HHS, 2014). Reducing cigarette smoking in the community can impact the health and health care costs of nonsmokers as well. CDC (Centers for Disease Control and Prevention). (2014a). CDC’s Tips from Former Smokers campaign provided outstanding return on investment. Atlanta, GA. Available at: http://www.cdc.gov/media/releases/2014/p1210-tips-roi.html. (Accessed 27 October, 2015). HHS (US Department of Health and Human Services). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. (Accessed 23 September, 2015). Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. (2014) Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine, 48(3), p.326-333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603661/ (Accessed 24 September, 2015). Jha, P. and Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 2014(370), p.60-68. Available at: http://www.nejm.org/doi/full/10.1056/nejmra1308383. (Accessed 22 October, 2015). doi: 10.1056/NEJMra1308383

Measure Specifications

Summary of NQF Endorsement Review




Appropriate Use Criteria - Cardiac Electrophysiology (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-398)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 – Appropriate Use Criteria for Implantable Cardioverter Defibrillators and Cardiac Resynchronization Therapy: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. Endorsed by the American Geriatrics Society. Russo, A., et al, J Amer Coll Cardiol, 2013; 61(12):1318-1368. content.onlinejacc.org/article.aspx?articleid=1659563 There are many factors affecting patient care and patient management. One of the most critical to patient management is to order the right testing to diagnose the pathology, disease process or condition. There is a plethora of published data outlining the negative impact that inappropriate diagnostic testing has on the patient and the health care system on many levels. There are several components that must be in place to ensure that the imaging tests are performed safely, and ordered appropriately. However, it starts with a baseline measurement of review, evaluation documentation. Once cannot put process improvement plans in place if they are not aware that they are needed. It is only through evaluating metrics at the physician level that provides a mechanism for behavioral change and fosters a culture of quality. IAC provides a QI tool for physicians to use to review, document and benchmark the AUC in their practices. The data is secure and can be queried and benchmarked for their own purpose or against their peers. Physicians/facilities sign a Business agreement with the IAC to use the QI tool. IAC ISO 9001 – 2008 project management and ISO 2700:2013 – Information Security certified, fully compliant with HITECH and HIPAA requirements and the data is confidential. IAC medical imaging accreditation obtains and verifies many metrics of quality to ensure better patient care leading to better patient outcomes.

Measure Specifications




Average change in back pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-087)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543

Measure Specifications




Average change in back pain following lumbar fusion. (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-088)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
According to the Journal of Neurosurgery: Spine’s Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine, the assessment of functional outcomes, including pain, continues to be essential. Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Ghogawala MD, Zoher, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: Assessment of functional outcome following lumbar fusion. Journal of Neurosurgery: Spine. Jul 2014. DOI: 10.3171/2014.4.SPINE14258 Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543

Measure Specifications




Average change in leg pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-089)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543

Measure Specifications




Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-287)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Androgen suppression as a treatment for prostate cancer can cause osteoporosis. (Gleason et al. General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness). Men undergoing prolonged androgen deprivation therapy (ADT) incur bone loss at a rate higher than menopausal women. (AUA. Business Cases in Urology: CRPC). In preserving bone health, the goal is to prevent or treat osteopenia /osteoporosis for the patient on ADT and to prevent or delay skeletal related events (SRE). The National Osteoporosis Foundation recommendations including a baseline assessment of bone density with a DEXA scan and daily calcium and Vitamin D supplementation. (Gaylis et al. Compliance with Evidence Based Bone Health Management in Men on chronic ADT: Opportunities for Improvement). The DEXA scan is the gold standard for bone density screening. Men at risk for adverse bone consequences from chronic ADT do not always receive care according to evidence based guidelines. These findings call for improved processes that standardize evidence based practice including baseline and follow up bone density assessment. (Gaylis et al).

Measure Specifications




Febrile Neutropenia Risk Assessment Prior to Chemotherapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-151)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Seven articles published from 2006 to 2016 provide insights into the benefits of FN risk assessment: Donohue (2006): Among patients receiving chemotherapy, the rates CSF prophylaxis were higher in those who were managed with a Risk Assessment Tool, than those in a “control group” that received care without use of the tool in an earlier time period (72% versus 28%, respectively, p<0.001). Conversely, the rates of adverse outcomes were higher in the control group than in the Risk Assessment Tool Group, but not statistically significant: febrile neutropenia (14% versus 11%, respectively), treatment with IV antibiotics (28% versus 14%), hospitalizations secondary to febrile neutropenia (16% versus 11%), and chemotherapy dose reductions (10% versus 3%). Doyle (2006): In a pre-post intervention study of patients initiating chemotherapy or a new regimen, use of tool for assessing patient risk of FN lowered the rate of FN-related hospitalization by 78%, from 9.7% among 155 patients in FY04 to 2.1% among 189 patients in FY05 (P = 0.003). Miller (2006): In a study of an intervention with a computer-based risk assessment tool (CBRAT), the rate of documenting performance of an FN risk assessment was 13% before use of the CBRAT and 100% after its introduction (p<0.001). O’Brien et al. (2014): An intervention study in a hospital-based oncology unit used an FN risk assessment tool to decide which patients receiving chemotherapy to treat with CSF. Comparing the time periods before (N=233 patients) and after (N=226 patients) the tool was used, the incidence of FN was reduced by 52% (p=0.02). Krzemieniecki et al. (2014): A total of 1,347 patients with solid tumors were eligible for the study based on being scheduled for “myelotoxic” chemotherapy and having an “investigator-assessed FN risk” of = 20%. The study found 45-80% of these patients, depending on the tumor site, did not receive G-CSF that was indicated by results of the FN risk assessment by the investigator and guideline recommendations. Freyer et al. (2015): In a study of 165 physicians and 944 patients, each physician rated FN risk for their own patients using factors they selected. Only 82% of patients with an FN risk at or above 20% based on the physician-assessed FN risk were scheduled to receive CSF indicating almost one of five patients would not receive G-CSF PP even though the patient’s risk was rated higher than the threshold of 20%. Mäenpää et al. (2016): In a study of 690 breast cancer patients (stages I-III) receiving chemotherapy, a higher proportion of those with a high-risk regimen were given G-CSF primary prophylaxis than those with a lower-risk regimen (48% versus 22%). However, these results indicate that less than half of patients on a high-risk regimen received appropriate treatment with G-CSF. References: Donohue, R. (2006). Development and implementation of a risk assessment tool for chemotherapy-induced neutropenia. Oncol Nurs Forum, 33(2), 347-352. Doyle, A. M. (2006). Prechemotherapy assessment of neutropenic risk. Oncology (Williston Park), 20(10 Suppl Nurse Ed), 32-39; discussion 39-40. Miller, K. (2010). Using a computer-based risk assessment tool to identify risk for chemotherapy-induced febrile neutropenia. Clin J Oncol Nurs, 14(1), 87-91. O'Brien, C., Dempsey, O., & Kennedy, M. J. (2014). Febrile neutropenia risk assessment tool: improving clinical outcomes for oncology patients. Eur J Oncol Nurs, 18(2), 167-174. Krzemieniecki, K., Sevelda, P., Erdkamp, F., Smakal, M., Schwenkglenks, M., Puertas, J., et al. (2014). Neutropenia management and granulocyte colony-stimulating factor use in patients with solid tumours receiving myelotoxic chemotherapy--findings from clinical practice. Support Care Cancer, 22(3), 667-677. Freyer, G., Kalinka-Warzocha, E., Syrigos, K., Marinca, M., Tonini, G., Ng, S. L., et al. (2015). Attitudes of physicians toward assessing risk and using granulocyte colony-stimulating factor as primary prophylaxis in patients receiving chemotherapy associated with an intermediate risk of febrile neutropenia. Med Oncol, 32(10), 236. Maenpaa, J., Varthalitis, I., Erdkamp, F., Trojan, A., Krzemieniecki, K., Lindman, H., et al. (2016). The use of granulocyte colony stimulating factor (G-CSF) and management of chemotherapy delivery during adjuvant treatment for early-stage breast cancer-Further observations from the IMPACT solid study. Breast, 25, 27-33.

Measure Specifications

Summary of NQF Endorsement Review




Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-074)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
The African-American Heart Failure Trial (A-HeFT) first published in 2004 demonstrated that there is significant benefit for African American patients who receive the fixed-dose combination therapy of hydralazine and isosorbide dinitrate. A-HeFT built on the findings from the two Vasodilator-Heart Failure Trials (V-HeFT). A-HeFT, which was ended early due to the mortality rates in the placebo population, demonstrated a 43% reduction in mortality, a 33% decrease in initial hospitalizations, and a 50% improvement in patient-reported quality of life (Taylor, 2004; Sharma, 2014). These results clearly demonstrate that the fixed-dose combination therapy significantly improves patient morbidity, mortality and quality of life in this clinical cohort. There is no substitute for the fixed-dose combination therapy. Even with this strong evidence of unprecedented efficacy and cost-effectiveness, research shows that more than 85% of African American patients are not receiving the quality of care that this therapy affords, constituting a significant gap in care quality (Dickson, 2015). The underuse of the fixed-dose combination of hydralazine plus isosorbide dinitrate in African Americans with severe heart failure is a health care and health quality disparity that exposes these patients to an elevated risk for mortality and hospitalization, and compromises efforts to contain the escalating system costs by preventing or reducing unnecessary hospitalizations and readmissions. Based upon research on the mortality benefit of the fixed-dose combination (Fonarow, 2011), the National Minority Quality Forum estimates that 51,542 (27%) of the 189,891 African American Medicare beneficiaries who were being treated for heart failure and received their prescription drugs under Part D should have been treated with the fixed-dose combination; but only 2,377 (5%) had at least one prescription (30-day supply) of the therapy. Further, the National Minority Quality Forum estimates that between 2008 and 2010, only 3% of the eligible patient cohort in Medicare received the therapy. Given the documented number to treat to receive the mortality benefit (21), it can be estimated that from 2007 through 2010, 20,000 African American Medicare beneficiaries died as a result of the failure to receive quality care as defined by evidence-based guidelines. The proven benefits to this patient population are significant and there is a clear opportunity for improvement. Failure to do so constitutes a failure to provide quality and cost-effective care. As with other diagnoses and available therapies, we anticipate that the evidence supporting this measure will continue to evolve. For example, research continues to explore if the fixed-dose combination of hydralazine and isosorbide dinitrate is linked to a particular genetic polymorphism (NIH funded Genomic Response Analysis of Heart Failure Therapy in African Americans). References Dickson VV, Knafl GJ, Wald J, Riegel B. Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure. J Am Heart Assoc. 2015;4:1-13. Fonarow GC, Yancy CW, Hernandez AF, Peterson ED, Spertus JA, Heidenreich PA. Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J. 2011;161:1024-1030. Sharma A, Colvin-Adams M, Yancy CW. Heart failure in African Americans: disparities can be overcome. Cleve Clin J Med. 2014;81:301-11. Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004; 351:2049–57.

Measure Specifications




HIV Medical Visit Frequency (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-073)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Early linkage to and long-term retention in HIV care leads to better health outcomes. Linkage to HIV medical care shortly after HIV diagnosis and continuous care thereafter provide opportunities for risk reduction counseling, initiation of treatment, and other strategies that improve individual health and prevent onward transmission of infection (1-6). Delayed linkage and poor retention in care are associated with delayed receipt of antiretroviral treatment, higher rate of virologic failure, and increased morbidity and mortality (5,7). Poor retention in care during the first year of outpatient medical care is associated with delayed or failed receipt of antiretroviral therapy, delayed time to virologic suppression and greater cumulative HIV burden, increased sexual risk transmission behaviors, increased risk of long-term adverse clinical events, and low adherence to antiretroviral therapy (1,5,7,9). Early retention in HIV care has been found to be associated with time to viral load suppression and 2-year cumulative viral load burden among patients newly initiating HIV medical care (8). References: 1. Giordano TP, Gifford AL, White AC Jr, Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007; 44:1493-9. 2. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al.; HPTN 052 Study Team. Prevention of HIV -1 infection with early antiretroviral therapy. N Engl J Med. 2011; 365:493-505. 3. Giordano TP, White AC Jr, Sajja P, Graviss EA, Arduino RC, Adu-Oppong A, et al. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndr. 2003; 32:399-405. 4. Lucas GM, Chaisson RE, Moore RD. Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions. Ann Intern Med. 1999; 131:81-7. 5. Metsch LR, Pereyra M, Messinger S, Del Rio C, Strathdee SA, Anderson-Mahoney P, et al.; Antiretroviral Treatment and Access Study (ART AS) Study Group. HIV transmission risk behaviors among HIV -infected persons who are successfully linked to care. Clin Infect Dis. 2008; 47:577-84. 6. Montaner JS, Lima VD, Barrios R, Yip B, Wood E, Kerr T, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010; 376:532- 9. 7. Ulett KB, Willig JH, Lin HY, Routman JS, Abrams S, Allison J, Chatham A, Raper JL, Saag MS, Mugavero MJ. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS. 2009 Jan; 23(1):41-9. 8. Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, Dombrowski JC, Norton WE, Raper JL, Kitahata MM, Saag MS. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012 Jan 1; 59(1):86-93. 9. Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, Abroms S, Raper JL, Saag MS, Allison JJ. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009 Jan 15;48(2):248-56.

Measure Specifications

Summary of NQF Endorsement Review




HIV Viral Suppression (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-075)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Sustained viral load suppression is directly related to reduction in disease progression and to reduction in potential for transmission of infection. Among persons in care, sustained viral load suppression represents the cumulative effect of prescribed therapy, ongoing monitoring, and patient adherence. The proposed measure will direct providers’ attention and quality improvement efforts towards this important outcome.

Measure Specifications

Summary of NQF Endorsement Review




Intravesical Bacillus Calmette-Guerin for NonMuscle Invasive Bladder Cancer (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-310)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
There are no bladder cancer measures, yet it is the 5th common cancer diagnosis in 2016. Failure to treat the bladder cancer in a nonmuscle invasive stage can lead to invasion into the muscle layer of the bladder, requiring bladder removal and further chemotherapy and/or radiation.

Measure Specifications




Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-269)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016) Data detailing the prescription of systemic antimicrobials for otitis media with effusion in children is limited. However, in a small 2008 study by Patel et al, 7% of physicians in an otolaryngology practice prescribed systemic antimicrobials for pediatric patients presenting with OME [1]. In a 2014 study involving 5 focus groups of parents, most parents believed that antibiotics were needed to treat otitis media and expressed frustration with a “watchful waiting” approach [2]. In a 2013 study by Forrest et al evaluating clinical decision support for management of OME, 78%-93% of physicians employed a “watchful waiting” strategy to manage OME [3]. 1. Patel MM, Eisenberg L, Witsell D, Schulz KA. Assessment of acute otitis externa and otitis media with effusion performance measures in otolaryngology practices. Otolaryngol Head Neck Surg. 2008;139:490-494. 2. Finkelstein JA, Dutta-Linn M, Meyer R, Goldman R. Childhood infections, antibiotics, and resistance: what are parents saying now? Clin Pediatr (Phila). 2014;53(2):145-150. Doi:10.1177/0009922813505902. 3. Forrest CB, Fiks AG, Bailey LC, et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics. 2013;131(4):e1071-e1081.

Measure Specifications

Summary of NQF Endorsement Review




Otitis Media with Effusion: Systemic Corticosteroids - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-268)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016) Data detailing the prescription of systemic corticosteroids for otitis media with effusion in children is limited. However, in a small 2008 study by Patel et al, 10% of physicians in an otolaryngology practice prescribed systemic corticosteroids for pediatric patients presenting with OME [1]. In a 2013 study by Forrest et al evaluating clinical decision support for management of OME, 78%-93% of physicians employed a “watchful waiting” strategy to manage OME [2]. 1. Patel MM, Eisenberg L, Witsell D, Schulz KA. Assessment of acute otitis externa and otitis media with effusion performance measures in otolaryngology practices. Otolaryngol Head Neck Surg. 2008;139:490-494. 2. Forrest CB, Fiks AG, Bailey LC, et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics. 2013;131(4):e1071-e1081.

Measure Specifications

Summary of NQF Endorsement Review




Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-291)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Surgeries are frequently performed procedures that affect large numbers of patients in the population, have high resource use, and poor quality can have serious consequences for patients, including death. Therefore, improving the quality of surgical care is of paramount importance to patients and the healthcare system alike. In a study based on the HCUP 2007 data, in 28 states that were evaluated, there were nearly 5,600 ambulatory surgery (AS) visits per 100,000 in the population and almost 4,100 inpatient surgical visits per 100,000. The mean charge for ambulatory surgery is about $6,100 and for inpatient surgery is about $39,900. The aggregate charge across the 28 states for ambulatory surgery was about $55.6 billion and the total inpatient charges were about $259 billion. Patient experience measures as indicators of quality for health plans are linked to health plan disenrollment. The mean voluntary disenrollment rate among Medicare managed care enrollees is four times higher for plans in the lowest 10 percent of overall CAHPS Health Plan survey ratings than for those in the highest 10 percent. At the provider level, patients who reported the poorest-quality relationships with their physicians are three times more likely to voluntarily leave the physician’s practice than patients with the highest-quality relationships. The quality of the provider-patient relationship as evident in good patient experience scores correlates with lower medical malpractice risk. Although average patient experience scores can mask variations within a provider’s scores, the minimum score a provider receives correlates with the likelihood of being implicated in a medical malpractice suit. Each drop in minimum overall score along a five-step scale of “very good” to “very poor” corresponds to a 21.7 percent increase in the likelihood of being named in a suit. Forty-six percent of malpractice risk is attributed to physician specific characteristics, including patient experience. Efforts to improve patient experience also result in greater employee satisfaction, reducing turnover. Improving patients’ experiences requires improving work processes and systems that enable clinicians and staff to provide effective care. A focused endeavor to improve patients’ experiences at one hospital also resulted in a 4.7 percent reduction in employee turnover. Similarly, nurse satisfaction is strongly positively correlated with patients’ intent to return to or to recommend the hospital.

Measure Specifications

Summary of NQF Endorsement Review




Prescription of HIV Antiretroviral Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-072)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
HIV Antiretroviral therapy reduces HIV-associated morbidity and mortality by maximally inhibiting HIV replication (as defined by achieving and maintaining plasma HIV RNA (viral load) below levels detectable by commercially available assays). Emerging evidence also suggests that additional benefits of ART-induced viral load suppression include a reduction in HIV-associated inflammation and possibly its associated complications.

Measure Specifications

Summary of NQF Endorsement Review




Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-312)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is highly dissatisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk factors for PONV; demonstrated effective prophylactic regimes based on these risk factors; and demonstrated high variability in this outcome across individual centers and providers (Kranke & Eberhart, 2011; Singla et al., 2010). Further, a number of papers have shown that performance can be assessed at the level of individual providers — the outcome is common enough that sufficient power exists to assess variability and improvement at this level (Dzwonczyk et al., 2012). A separate measure is needed for pediatric patients because the risk factors and recommended prophylaxis are different from adults. Dzwonczyk R, Weaver TE, Puente EG, Bergese SD. Postoperative nausea and vomiting prophylaxis from an economic point of view. Am J Ther. 2012 Jan;19(1):11-5. Kranke P, Eberhart LH. Possibilities and limitations in the pharmacological management of postoperative nausea and vomiting. Eur J Anaesthesiol. 2011 Nov;28(11):758-65. Singla NK, Singla SK, Chung F, Kutsogiannis DJ, Blackburn L, Lane SR, Levin J, Johnson B, Pergolizzi JV Jr. Phase II study to evaluate the safety and efficacy of the oral neurokinin-1 receptor antagonist casopitant (GW679769) administered with ondansetron for the prevention of postoperative and postdischarge nausea and vomiting in high-risk patients. Anesthesiology. 2010;113(1):74-82.

Measure Specifications




Safety Concern Screening and Follow-Up for Patients with Dementia (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-317)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse (Category I). Important safety issues in the management of patients with dementia include interventions to decrease the hazards of wandering and recommendations concerning activities such as cooking, driving, hunting, and the operation of hazardous equipment. Caregivers should be referred to available books [and other materials] that provide advice and guidance about maximizing the safety of the environment for patients with dementia…As patients become more impaired, they are likely to require more supervision to remain safe, and safety issues should be addressed as part of every evaluation. Families should be advised about the possibility of accidents due to forgetfulness (e.g., fires while cooking), of difficulties coping with household emergencies, and of the possibility of wandering. Family members should also be advised to determine whether the patient is handling finances appropriately and to consider taking over the paying of bills and other responsibilities. At this stage of the disease [i.e., moderately impaired patients], nearly all patients should not drive. (1) For mild to moderate Alzheimer's disease Assess for safety risks (e.g., driving, financial management, medication management, home safety risks that could arise from cooking or smoking, potentially dangerous behaviors such as wandering) (2) 1. American Psychiatric Association (APA). Practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Arlington (VA): American Psychiatric Association (APA). October 2007 85 p. 2. Chertkow H. Diagnosis and treatment of dementia: introduction. Introducing a series based on the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. CMAJ. 2008;178:316-321.

Measure Specifications




Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-343)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
This measure ensures documentation of two important procedural aspects of uterine artery embolization, which are known to be associated with treatment efficacy: (1) appropriate embolization endpoints achieved and (2) delineation of all uterine arterial supply with embolization where possible. Inadequate embolization alone is a known cause of treatment failure1. The ovarian arteries often provide an alternate route of arterial supply to the uterus when the uterine artery is occluded or absent; however routine aortography is not recommended when conventional uterine artery anatomy is present2. 1. Dariushnia SR et al. Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic leiomyomata. JVIR 2014; 25:1737-1747. 2. White AM et al. Patient radiation exposure during uterine fibroid embolization and the dose attributable to aortography. JVIR 2007; 18:573-576.

Measure Specifications




Adult Local Current Smoking Prevalence (Program: Medicare Shared Savings Program; MUC ID: MUC16-069)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Cigarette smoking is still the leading preventable cause of death and disease in the U.S. and costs the U.S. health care system nearly $170 billion in direct medical care for adults each year (CDC 2014a; HHS 2014; Xu et al. 2014). Currently more than 16 million US residents are living with a smoking-related illness (HHS 2014). Smoking harms nearly every organ in the body and has been causally linked to numerous cancers, heart disease and stroke, chronic obstructive pulmonary disease, pneumonia, other respiratory diseases, aortic aneurysm, peripheral vascular disease, cataracts and blindness, age-related macular degeneration, periodontitis, diabetes, pregnancy and reproductive complications, bone fractures, arthritis, and reduced immune function (HHS, 2014). Mortality among current smokers is two to three times that of persons who never smoked (Jha et al. 2013). Since the first Surgeon General’s Report on Smoking and Health in 1964, cigarette smoking has killed more than 20 million people in the U.S. (HHS 2014). Between 2005-2009, 87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all coronary heart disease deaths were attributable to smoking and secondhand smoke exposure (HHS, 2014), making it an essential risk factor to address to reduce both disease burden and health care costs. The toll smoking takes on health extends beyond the smokers. Since 1964, almost 2.5 million nonsmoking adults have died from heart disease and lung cancer caused by exposure to secondhand smoke, and 100,000 babies have died of sudden infant death syndrome or complications from prematurity, low birth weight, or other conditions caused by parental smoking, particularly smoking by the mother (HHS, 2014). Reducing cigarette smoking in the community can impact the health and health care costs of nonsmokers as well. CDC (Centers for Disease Control and Prevention). (2014a). CDC’s Tips from Former Smokers campaign provided outstanding return on investment. Atlanta, GA. Available at: http://www.cdc.gov/media/releases/2014/p1210-tips-roi.html. (Accessed 27 October, 2015). HHS (US Department of Health and Human Services). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. (Accessed 23 September, 2015). Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. (2014) Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine, 48(3), p.326-333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603661/ (Accessed 24 September, 2015). Jha, P. and Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 2014(370), p.60-68. Available at: http://www.nejm.org/doi/full/10.1056/nejmra1308383. (Accessed 22 October, 2015). doi: 10.1056/NEJMra1308383

Measure Specifications

Summary of NQF Endorsement Review




PRO utilization in in non-metastatic prostate cancer patients (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-393)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Neil E. Martin, Laura Massey, Caleb Stowell, et al. Defining a Standard Set of Patient-centered Outcomes for Men with Localized Prostate Cancer. Eur Urol 2015;67:460–7 Stover A, Irwin DE, Chen RC, Chera BS, Mayer DK, Muss HB, Rosenstein DL, Shea TC, Wood WA, Lyons JC, Reeve BB; Integrating Patient-Reported Outcome Measures into Routine Cancer Care: Cancer Patients’ and Clinicians’ Perceptions of Acceptability and Value. eGEMS. 2015 Oct. 3(1): 1169. Available at: http://repository.edm-forum.org/egems/vol3/iss1/17 Wei JT, Dunn RL, Litwin MS, Sandler HM, Sanda MG. "Development and Validation of the Expanded Prostate Cancer Index Composite (EPIC) for Comprehensive Assessment of Health-Related Quality of Life in Men with Prostate Cancer", Urology. 56: 899-905, 2000. Wei JT, Dunn RL, Sandler HM, McLaughlin PW, Montie JE, Litwin MS, Nyquist L, Sanda MG. Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer ", Journal of Clinical Oncology. 20(2): 557-66, 2002. Hollenbeck BK, Dunn RL, Wei JT, McLaughlin PW, Han M, Sanda MG. Neoadjuvant hormonal therapy and older age are associated with adverse sexual health-related quality-of-life outcome after prostate brachytherapy ", Urology. 59: 480-4, 2002. Hollenbeck BK, Dunn RL, Wei JT, Montie JE, Sanda MG. Determinants of Long-Term Sexual HRQOL After Radical Prostatectomy Measured by a Validated Instrument", Journal of Urology. 169: 1453-7, 2003. Van Andel G, Bottomley A, Fossa SD, Efficace F, Coens C, Guerif S, Kynaston H, Gontero P, Thalmann G, Akdas A, D’Haese S, Aronson NK An international field study of the EORTC QLQ-PR25: a questionnaire for assessing the health-related quality of life of patients with prostate cancer. Eur J Cancer. 2008 Nov;44(16):2418-24. doi: 10.1016/j.ejca.2008.07.030. Epub 2008 Sep 5. Sonn GA, Sadetsky N, Presti JC, Litwin M. Differing perceptions of quality of life in patients with prostate cancer and their doctors. J Urol 2009; 182: 2296–2302. Justice AC, Rabeneck L, Hays RD, Wu AW, Bozzette SA. Sensitivity, specificity, reliability, and clinical validity of provider-reported symptoms: a comparison with self-reported symptoms. J Acquir Immune Defic Syndr 1999; 21: 126–133.

Measure Specifications




Proportion of patients who died from cancer admitted to hospice for less than 3 days (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-274)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Langton, J. M., B. Blanch, et al. (2014). "Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review." Palliat Med 28(10): 1167-1196. Lee, Y. J., J. H. Yang, et al. (2015). "Association between the duration of palliative care service and survival in terminal cancer patients." Support Care Cancer 23(4): 1057-1062. O´Connor, T. L., N. Ngamphaiboon, et al. (2015). "Hospice utilization and end-of-life care in metastatic breast cancer patients at a comprehensive cancer center." J Palliat Med 18(1): 50-55.

Measure Specifications

Summary of NQF Endorsement Review




Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-273)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Zhang B, Nilsson ME, Prigerson HG. Factors important to patients´ quality of life at the end of life. Arch Intern Med 2012;172:1133-1142.Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806298/ Wright AA, Keating NL, Balboni TA, et al. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol 2010; 28:4457–4464. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988637/ Langton JM, Blanch B, Drew AK, et al. Retrospective studies of end of-life resource utilization and costs in cancer care using health administrative data: a systematic review. Palliat Med 2014;28:1167-1196. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24866758. Kao YH, Chiang JK. Effect of hospice care on quality indicators of end-of-life care among patients with liver cancer: a national longitudinal population based study in Taiwan 2000-2011. BMC Palliat Care 2015: 14:39. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4545784/#CR5 Barbera L, Seow H, et al. Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data. Curr Oncol 2015 Oct: 22(5): 341-355. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608400/

Measure Specifications

Summary of NQF Endorsement Review




Proportion of patients who died from cancer not admitted to hospice (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-275)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Smith, T. J., S. Temin, et al. (2012). "American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care." J Clin Oncol 30(8): 880-887. O´Connor, T. L., N. Ngamphaiboon, et al. (2015). "Hospice utilization and end-of-life care in metastatic breast cancer patients at a comprehensive cancer center." J Palliat Med 18(1): 50-55. Lee, Y. J., J. H. Yang, et al. (2015). "Association between the duration of palliative care service and survival in terminal cancer patients." Support Care Cancer 23(4): 1057-1062. Langton, J. M., B. Blanch, et al. (2014). "Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review." Palliat Med 28(10): 1167-1196. Guadagnolo, B. A., K. P. Liao, et al. (2015). "Variation in Intensity and Costs of Care by Payer and Race for Patients Dying of Cancer in Texas: An Analysis of Registry-linked Medicaid, Medicare, and Dually Eligible Claims Data." Med Care 53(7): 591-598.

Measure Specifications

Summary of NQF Endorsement Review




Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-271)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
El-Jawahri, A. R., G. A. Abel, et al. (2015). "Health care utilization and end-of-life care for older patients with acute myeloid leukemia." Cancer 121(16): 2840-2848. Mack, J. W., A. Walling, et al. (2015). "Patient beliefs that chemotherapy may be curative and care received at the end of life among patients with metastatic lung and colorectal cancer." Cancer 121(11): 1891-1897.

Measure Specifications

Summary of NQF Endorsement Review




Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-142)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Measure Specifications

Summary of NQF Endorsement Review




Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-314)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications




Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-323)

Summary of Workgroup Deliberations

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications




Appendix B: Program Summaries

 The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program Index


Full Program Summaries

Inpatient Rehabilitation Facility Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 of 2014 (IMPACT Act) 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 (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure 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; and the 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. The IMPACT Act 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; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following four domains as high-priority for future measure consideration:

1. 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 efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.

2. Communication/Care Coordination: Assessing resident care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.

3. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the IRF QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Medication reconciliation conceptually highlights care transitions and resident follow-up. Therefore, a medication reconciliation quality measure for IRF patients is being considered for future quality measure development. 

4. Communication/Care Coordination: Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many patients for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, a discharge to community measure for IRFs is being considered for the future use in the IRF QRP.

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

Skilled Nursing Facility Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Improving Medicare Post-Acute Care Transitions Act of 2014 (The IMPACT Act) added Section 1899B to the Social Security Act establishing the Skilled Nursing Facility Quality Reporting Program (SNF QRP). Facilities that submit data under the SNF PPS are required to participate in the SNF QRP, excluding units that are affiliated with critical access hospitals (CAHs). Data sources for SNF QRP measures include Medicare FFS claims as well as Minimum Data Set (MDS) assessment data. The SNF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2018, providers that fail to submit required quality data to CMS will have their annual updates reduced by 2.0 percentage points. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) 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 (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure 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; and the 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. The IMPACT Act 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; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration:
  1. Making Care Affordable: An important consideration for the SNF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
  2. Communication/Care Coordination: Assessing resident care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
  3. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the SNF QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Therefore, a medication reconciliation quality measure for SNF residents is being considered for future quality measure development.
  4. Communication/Care Coordination: Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many residents for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, a discharge to community measure for SNFs is being considered for the future use in the SNF QRP.

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

Home Health Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Home Health Quality Reporting Program (HH QRP) was established in accordance with section 1895 (b)(3)(B)(v)(II) of the Social Security Act. Home Health Agencies (HHAs) are required by the Act to submit quality data for use in evaluating quality for Home Health agencies. Section 1895(b) (3)(B)(v)(I) of the Act also requires that HHAs that do not submit quality data to the Secretary be subject to a 2 percent reduction in the annual payment update, effective in calendar year 2007 and every subsequent year. Data sources for the HH QRP include the Outcome and Assessment Information Set (OASIS) and Medicare FFS claims. Data is publically reported on the Home Health Compare website. The HH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) 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 (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure 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; and the 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. The IMPACT Act 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; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration:

  1. Patient and Family Engagement: Functional status and functional decline are important to assess for residents in HH settings. Patients who receive care while in a HH may have functional limitations and may be at risk for further decline in function due to limited mobility and ambulation. Therefore, measures to assess functional status are in development.
  2. Making Care Safer: Safety for individuals in a home-based setting is an important priority for the HH QRP as persons in home health settings are at risk for major injury due to falls, new or worsened pressure ulcers, pain, and functional decline. Therefore, these concepts will be considered for future measure development.
  3. Making Care Affordable: An important consideration for the HH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.
  4. Communication/Care Coordination: Assessing an individual’s care transitions and rehospitalizations is important. Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many individuals for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
  5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the HH QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Therefore, a medication reconciliation quality measure for individuals in a home health setting is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

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

Long-Term Care Hospital Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 of 2014 (IMPACT Act) 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 (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure 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; and the 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. The IMPACT Act 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; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for LTCH QRP future measure consideration:

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

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

Hospice Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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

High Priority Domains for Future Measure Consideration:

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

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

Medicare Shared Savings Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: Section 3022 of the Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a Shared Savings Program that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery. The Medicare Shared Savings Program (MSSP) was designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). If ACOs meet program requirements and the ACO quality performance standard, they are eligible to share in savings, if earned. There are three shared savings options: 1) one- sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year), 2) two-sided risk model (sharing of savings and losses for all three years), and 3) two-sided risk model (sharing of savings and losses for all three years) with prospective assignment

High Priority Domains for Future Measure Consideration: N/A

Measure Requirements:

Specific measure requirements include:

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

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

Merit-Based Incentive Payment System 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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

High Priority Domains for Future Measure Consideration:

CMS will not propose the implementation of measures that do not meet the MIPS criteria of performance and measure set gaps. MIPS has a priority focus on outcome measures and measures that are relevant for specialty providers. CMS identifies the following domains as high-priority for future measure consideration:

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

In addition, CMS identified the following measure types as high-priority for future measure consideration:

  1. Outcome measures
  2. Appropriate Use of Services measures
  3. Patient Experience measures
  4. Care Coordination measures

Measure Requirements:

CMS applies criteria for measures that may be considered for potential inclusion in the MIPS. At a minimum, the following criteria and requirements must be met for selection in the MIPS: CMS is statutorily required to select measures that reflect consensus among affected parties, and to the extent feasible, include measures set forth by one or more national consensus building entities. To the extent practicable, quality measures selected for inclusion on the final list will address at least one of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention. In addition, before including a new measure in MIPS, CMS is required to submit for publication in an applicable specialty-appropriate, peer-reviewed journal the measure and the method for developing the measure, including clinical and other data supporting the measure.

  1. Measures implemented in MIPS may be available for public reporting on Physician Compare.
  2. Preference will be given to electronically specified measures (eCQMs)
  3. eCQMs must meet EHR system infrastructure requirements, as defined by the future MIPS regulation.
    • The data collection mechanisms must be able to transmit and receive requirements as identified in future MIPS regulation. For example, eCQMs must meet QRDA standards.
  4. Measures must be fully developed and tested.
    • Reliability and validity testing must be conducted for measures.
    • Feasibility testing must be conducted for eCQMs.
  5. Measures should not duplicate other measures currently in the MIPS. Duplicative measures are assessed to see which would be the better measure for the MIPS measure set.
  6. Measure performance and evidence should identify opportunities for improvement. CMS does not intend to implement measures in which evidence identifies high levels of performance with little variation or opportunity for improvement, e.g., measures that are “topped out."

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

Ambulatory Surgical Center Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Ambulatory Surgical Center Quality Reporting Program (ASCQR) 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:

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

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

Measure Requirements:

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

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

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

End-Stage Renal Disease Quality Incentive Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: For more than 30 years, monitoring the quality of care provided to end-stage renal disease (ESRD) patients by dialysis facilities has been an important component of the Medicare ESRD payment system. The ESRD quality incentive program (QIP) is the most recent step in fostering improved patient outcomes by establishing incentives for dialysis facilities to meet or exceed performance standards established by CMS. The ESRD QIP is authorized by section 1881(h) of the Social Security Act, which was added by section 153(c) of Medicare Improvements for Patients and Providers (MIPPA) Act (the Act). CMS established the ESRD QIP for Payment Year (PY) 2012, the initial year of the program in which payment reductions were applied, in two rules published in the Federal Register on August 12, 2010, and January 5, 2011 (75 FR 49030 and 76 FR 628, respectively). Subsequently, CMS published rules in the Federal Register detailing the QIP requirements for PY 2013 through FY 2016. Most recently, CMS published a rule on November 6, 2014 in the Federal Register (79 FR 66119), providing the ESRD QIP requirements for PY2017 and PY 2018, with the intention of providing an additional year between finalization of the rule and implementation in future rules. Section 1881(h) of the Act requires the Secretary to establish an ESRD QIP by (i) selecting measures; (ii) establishing the performance standards that apply to the individual measures; (iii) specifying a performance period with respect to a year; (iv) developing a methodology for assessing the total performance of each facility based on the performance standards with respect to the measures for a performance period; and (v) applying an appropriate payment reduction to facilities that do not meet or exceed the established Total Performance Score (TPS).

High Priority Domains for Future Measure Consideration:

CMS identified the following 3 domains as high-priority for future measure consideration:

  1. Care Coordination: ESRD patients constitute a vulnerable population that depends on a large quantity and variety medication and frequent utilization of multiple providers, suggesting medication reconciliation is a critical issue. Dialysis facilities also play a substantial role in preparing dialysis patients for kidney transplants, and coordination of dialysis-related services among transient patients has consequences for a non-trivial proportion of the ESRD dialysis population.
  2. Safety: ESRD patients are frequently immune-compromised, and experience high rates of blood stream infections, vascular access-related infections, and mortality. Additionally, some medications provided to treat ESRD patients may cause harmful side effects such as heart disease and a dynamic bone disease. Recently, oral-only medications were excluded from the bundle payment, increasing need for quality measures that protect against overutilization of oral-only medications.
  3. Patient- and Caregiver-Centered Experience of Care: Sustaining and recovering patient quality of life was among the original goals of the Medicare ESRD QIP. This includes such issues as physical function, independence, and cognition. Quality of Life measures should also consider the life goals of the particular patient where feasible, to the point of including Patient-Reported Outcomes.
  4. Access to Transplantation: Obtaining a transplant is an extended process for dialysis patients, including education, referral, waitlisting, transplantation, and follow-up care. The care and information available from dialysis facilities are integral to the process. Complicating the issue of attribution are the role of transplant facilities in setting criteria and making decisions about transplant candidates and the limited availability of donor organs. Measures for the ESRD QIP must balance the role of the facility and other providers with the need to make transplants accessible to as many candidate recipients as possible.

Measure Requirements:

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

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

Hospital Acquired Condition Reduction Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: Section 3008 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the HospitalAcquired Condition Reduction Program (HACRP). Created under Section 1886(p) of the Social Security Act (the Act), the HACRP provides an incentive for hospitals to reduce the number of HACs. Effective Fiscal Year (FY) 2014 and beyond, the HACRP requires the Secretary to make payment adjustments to applicable hospitals that rank in the top quartile of all subsection (d) hospitals relative to a national average of HACs acquired during an applicable hospital stay. HACs include a condition identified in subsection 1886(d)(4)(D)(iv) of the Act and any other condition determined appropriate by the Secretary. Section 1886(p)(6)(C) of the Act requires the HAC information be posted on the Hospital Compare website. CMS finalized in the FY 2014 IPPS/LTCH PPS final rule that hospitals will be scored using a Total HAC Score based on measures categorized into two (2) domains of care, each with a different set of measures. Domain 1 consists of Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), and Domain 2 consists of Hospital Associated Infections (HAI) as collected by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Both domains of the HAC Reduction Program are categorized under the National Quality Strategy (NQS) priority of “Making Care Safer.” The Total HAC Score is the sum of the two weighted domain scores, with Domain 1 weighted at 15% and Domain 2 weighted at 85%.

High Priority Domains for Future Measure Consideration:

For FY 2017 federal rulemaking, CMS may propose the adoption, removal, and/or suspensionof measures for fiscal years 2018 and beyond of the HACRP. CMS identified the following topics as areas within the NQS priority of “Making Care Safer” for future measure consideration:

Making Care Safer:

  1. Adverse Drug Events
  2. Ventilator Associated Events
  3. Additional Surgical Site Infection Locations
  4. Outcome Risk-Adjusted Measures
  5. Diagnostic Errors
  6. All-Cause Harm

Measure Requirements:

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

  • Measures must be identified as a HAC under Section 1886(d)(4)(D) or be a condition identified by the Secretary.
  • Measures must address high cost or high volume conditions.
  • Measures must be easily preventable by using evidence-based guidelines.
  • Measures must not require additional system infrastructure for date submission and collection.
  • Measures must be risk adjusted.
  • Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

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

Hospital Inpatient Quality Reporting and EHR Incentive Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Hospital Inpatient Quality Reporting (HIQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and expanded by the Deficit Reduction Act 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 that fail to meet the requirements of the HIQR will result in a reduction of one-fourth to their fiscal year IPPS annual payment update (the annual payment update includes inflation in costs of goods and services used by hospitals in treating Medicare patients). Hospitals that choose to not participate in the program receive a reduction by that same amount. Hospitals not included in the HIQR, such as critical access hospitals and hospitals located in Puerto Rico and the U.S. Territories, are permitted to participate in voluntary quality reporting. Performance of quality measures are publicly reported on the CMS Hospital Compare website. The American Recovery and Reinvestment Act of 2009 amended Titles XVIII and XIX of the Social Security Act to authorize incentive payments to eligible hospitals (EHs) and critical access hospitals (CAHs) that 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 Programs. All EHR Incentive Program requirements related to eCQM reporting will be addressed in IPPS rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, alignment efforts between the HIQR and the Medicare EHR Incentive Program for EHs and CAHs, and information regarding the eCQMs.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

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

Measure Requirements:

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

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

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

Hospital Outpatient Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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

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

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

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

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

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

Hospital Readmissions Reduction Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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

High Priority Domains for Future Measure Consideration:

For FY 2017 federal rulemaking, CMS may propose the adoption, removal, refinement, and or suspension of measures for fiscal year 2018 and subsequent years of the HRRP. CMS continuesto emphasize the importance of the NQS priority of “Communication/Care Coordination” for this program.

  • Care Coordination
    • Measures that address high impact conditions identified by the Medicare Payment Advisory Commission or the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP)reports.

Measure Requirements:

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

  • CMS is statutorily required to select measures for applicable conditions, which are defined as conditions or procedures selected by the Secretary in which readmissions are high volumeor high expenditure.
  • Measures selected must be endorsed by the consensus-based entity with a contract under Section 1890 of the Act. However, the Secretary can select measures which are feasibleand practical in a specified area or medical topic determined to be appropriate by the Secretary, that have not been endorsed by the entity with a contract under Section 1890 of the Act, as longas endorsed measures have been given due consideration.
  • Measure methodology must be consistent with other readmissions measures currently implemented or proposed in the HRRP.
  • Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

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

Hospital Value-Based Purchasing Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Hospital Value-Based Purchasing (HVBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made each 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. In addition, 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 HVBP Program based on the statutory requirements, including specification under the Hospital Inpatient Quality Reporting (HIQR) Program and posting dates on the Hospital Compare website.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Patient and Family Engagement:
    1. Measures that foster the engagement of patients and families as partners in their care.
  2. Making Care Affordable:
    1. Measures that effectuate changes in efficiency and reward value over volume.

Measure Requirements:

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

  1. Measure must adhere to CMS statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare website.
    • 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
  2. Measure may not require reporting to a proprietary registry.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be fully developed, tested, and validated in the acute inpatient setting.
  5. 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.
  6. Measure must promote alignment across HHS and CMS programs.
  7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

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

Inpatient Psychiatric Facility Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program was established by Section 1886(s)(4) of the Social Security Act, as added by sections 3401(f)(4) and 10322(a) of the Patient Protection and Affordable Care Act (the Affordable Care Act). Under current regulations, the program requires participating inpatient psychiatric facilities (IPFs) to report on 16 quality measures or face a 2.0 percentage point reduction to their annual update. Reporting on these measures apply to payment determinations for Fiscal Year (FY) 2017 and beyond.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

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

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IPFQR. At a minimum, the following criteria will be considered in selecting measures for IPFQR 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 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. The measure assesses meaningful performance differences between facilities. The measure addresses an aspect of care affecting a significant proportion of IPF patients. 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 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.

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

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: Section 3005 of the Affordable Care Act added new subsections (a)(1)(W) and (k) to section 1866 of the Social Security Act (the Act). Section 1866(k) of the Act establishes a quality reporting programfor hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as a “PPS-Exempt Cancer Hospital” or PCHQR). Section 1866(k)(1) of the Act states that, for FY 2014 and each subsequent fiscal year, a PCH shall submit data to the Secretary in accordance with section 1866(k)(2) of the Act with respect to such a fiscal year. In FY 2014 and each subsequent fiscal year, each hospital described in section 1886(d)(1)(B)(v) of the Act shall submit data to the Secretary on quality measures (QMs) specified under section 1866(k)(3) of the Act in a form and manner, and at a time, specified by the Secretary. The program requires PCHs to submit data for selected QMs to CMS. PCHQR is a voluntaryquality reporting program, in which data will be publicly reported on a CMS website. In the FY 2012 IPPSrule, five NQF endorsed measures were adopted and finalized for the FY 2014 reporting period, which was the first year of the PCHQR. In the FY 2013 IPPS rule, one additional measure wasadopted. Twelve new measures were adopted in the FY 2014 IPPS rule and one measure was adopted in theFY 2015 IPPS rule. Data collection for the FY 2017 and FY 2018 reporting periods is underway.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

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

Measure Requirements: The following requirements will be considered by CMS when selecting measures forprogram implementation: Measure is responsive to specific program goals and statutory requirements. Measures are required to reflect consensus among stakeholders, and to the extent feasible, be endorsed by the national consensus entity with a contract underSection 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 specifications must be publicly available. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed. Promote alignment with specific program attributes and across CMS and HHSprograms. Measure alignment should support the measurement across the patient’s episode of care, demonstrated by assessment of the person’s trajectory across providers and settings. Potential use of the measure in a program does not result in negative unintended consequences (e.g., inappropriate reduced lengths of stay, overuse or inappropriate use of care ortreatment, limiting access to care). Measures must be fully developed and tested, preferably in the PCHenvironment. Measures must be feasible to implement across PCHs, e.g., calculation, and reporting. Measure addresses an important condition/topic with a performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs. CMS has the resources to operationalize and maintain the measure.

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

Appendix C: Public Comments

Index of Measures (by Program)

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

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Home Health Quality Reporting Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Hospice Quality Reporting Program

Hospital Value-Based Purchasing Program

Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Rehabilitation Facility Quality Reporting Program

Long-Term Care Hospital Quality Reporting Program

Merit-Based Incentive Payment System

Medicare Shared Savings Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program

Skilled Nursing Facility Quality Reporting Program

Full Comments (Listed by Measure)

General
  • January 9, 2017 Elizabeth McGlynn, PhD, MPP and George Isham, MD, MS Coordinating Committee Co-Chairs Measures Application Partnership 1030 15th Street, NW Washington, DC 20005 Dear Drs. McGlynn and Isham: On behalf of the American Osteopathic Association (AOA) and the close to 130,000 osteopathic physicians and osteopathic medical students we represent, thank you for the opportunity to respond to the Measures Application Partnership’s (MAP) 2017 Considerations for Implementing Measures in Federal Programs: MIPS and MSSP. The osteopathic profession strongly supported passage of the Medicare Access and CHIP Reauthorization Act (MACRA), and remains optimistic as we move towards a system that aligns well with the osteopathic philosophy of care – treating the whole person with a strong focus on prevention, wellness, and quality. During the law’s development, the AOA was especially supportive of MACRA’s focus on the value of care provided over volume. As defined in MACRA statute, the Merit-based Incentive Payment Systems (MIPS) creates a new framework for assigning value to care. The MAP is strongly positioned to favorably shape the implementation of the MIPS program and we are pleased to provide the following comments to the MAP as it undertakes this effort: 1. We support MAP’s efforts to include high-value measures. The osteopathic approach to medicine supports high-quality care in which patient-centeredness and coordination across members of the care team are hallmarks. These fundamental aspects of high quality care should be recognized through appropriate care measures. As such, we support the inclusion of “high-value” measures, including team-based care measures and patient-centered care measures, that reflect this model of care. Regarding outcome measures, we support the development of these metrics with caution that they appropriately include work performed by the care team. Further, we offer that both risk adjustment and socio-economic factors should be considered in the development of outcomes measures. This approach will incentivize the continuation of care to high-risk and high-need patients for whom care teams must contribute significantly more resources to achieve favorable outcomes. In addition, we caution that patient-reported measures must reflect the patient’s clinical experience and not be inclusive of non-clinical factors over which the care team does not have control. Physicians should be measured against metrics which they can reasonably control. MAP 1/9/2017 Page 2 Regarding appropriate use measures, we applaud the intent to base clinical care on evidence. AOA has long been a supporter of the Choosing Wisely campaign, but we caution that a cookie-cutter approach to medicine would be a disservice to patients. As such, appropriate use measures should be developed only when there is an abundance of established evidence in both the literature and in clinical practice, and should incorporate flexibility for physicians to weigh the patient’s unique circumstances. 2. We support MAP’s work to pursue appropriate attribution within measures. As attribution will be increasingly used in federal programs, in particular MIPS’ resource use performance category, we urge all stakeholders to pursue measures that can be appropriately attributed to members of the care team. We acknowledge that the coordinated, team-based model of care which yields high-quality care also complicates attribution. However, we strongly feel that proven models of care should not be minimized in order to simplify attribution methods. We recognize that these attribution challenges also include the timeliness of attribution and that the metric attributed to the physician should relate to an outcome that the physician could reasonably influence. We therefore offer that MAP may be positioned to develop parameters for attribution though a collaborative process, and that all measures should be measured against these criteria during the consideration process. 3. We oppose MAP’s efforts to remove topped out measures. We oppose the removal of topped out measures as defined by measures on which eligible clinicians perform well with little room for improvement. High performance on a particular measure, if aligned appropriately with the goal of improving quality, should be rewarded and more importantly should be incentivized to maintain – this, after all, is the essence of improving patient care. While we understand that MAP seeks to incentivize continued growth, the continued increase of performance measures and thresholds, while tied to payment under MIPS and MSSP, creates an exhausting system in which eligible clinicians have little opportunity to consider innovative practices because they are instead continually meeting rising prescriptive thresholds. This system can be a disadvantage for both patients and the health care system which can benefit from the innovative solutions developed by physicians when provided with the opportunity and resources to make such changes. We urge MAP to leave room for innovation and organic growth, rather than developing increasing prescriptive measures. 4. We support a collaborative, transparent, and timely process for measure development and evaluation that will maximize efficiencies and shared knowledge across stakeholders. Though current measures are numerous, disparate measure development has resulted in redundancies that should be streamlined. Collaborative measure development that includes relevant stakeholders will enable future measures to be better aligned with existing measure gaps, and without duplication of efforts or products. As such, it is vital that measure development and evaluation be a transparent process to which relevant stakeholders are invited. MAP 1/9/2017 Page 3 Please do not hesitate to call on the AOA for insight as you complete this report. To do so, or for additional information, please contact Laura Wooster, Interim Senior Vice President for Public Policy, atlwooster@osteopathic.org, or (202) 349-8747. Sincerely, Boyd R. Buser, DO President (Submitted by: American Osteopathic Association)

  • CAPC thanks the Clinician workgroup for the opportunity to review and comment on its draft report. We fully support the priorities identified in the subsection “Move to High-Value Measures” (pp. 3-5), as several of these have implications for the care of seriously ill patients. In regards to the need for new and/or improved patient-reported outcome measures, it might be worth noting that any new measures should have some mechanism to account for instances in which patients’ illness progress to a point where they are unable to advocate for themselves (e.g., proxy reporting). Acknowledging the large number of competing priorities in new measure development, we also want to suggest a few other possible priority areas including care consistency with patient preferences for treatment, access to palliative care, and financial toxicity. We also want to note that while we initially supported the inclusion of measures #278, 284, and 288 from the American College of Surgeons (ACS) for use in the Merit-based Incentive Payment System (MIPS), we respect how the workgroup came to its recommendation for this pre-rulemaking cycle (p. 4). We would, however, strongly support consideration of these measures in future MAP cycles if ACS is able to complete further testing and development as requested by the workgroup. As a general rule, there is a pressing need for more palliative care-relevant, cross-cutting measures in MIPS (p. 6). Currently, a majority of measures in this program are limited to a single setting or diagnosis; however, palliative care clinicians care for seriously ill patients across care settings and diagnoses, and many have reported difficulty reaching a minimum number of quality measures that are appropriate for their patient populations. Therefore we request that the workgroup highlight this as a priority area. Finally, CAPC supports the use of Choosing Wisely and other existing recommendations to determine whether MIPS and MSSP measures are indeed appropriate (p. 5). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • January 13, 2017 Measure Applications Partnership c/o National Quality Forum 1030 15th Street, NW Suite 800 Washington, DC 20005 Subject: MAP Pre-Rulemaking Report, Public Comment To Whom It May Concern: On behalf of the Society of General Internal Medicine (SGIM), thank you for the opportunity to comment on the Measure Applications Partnership (MAP)’s draft Pre-Rulemaking Report. We greatly appreciate MAP undertaking this important work. SGIM represents 3,000 general internists across the country who are deeply involved in providing primary medical care to Medicare beneficiaries, as well as in training the primary care providers of the future and engaging in health services research. We would like to take this opportunity to comment on the need for more outcome measures and balance between broadly applicable measures to help ensure alignment, reduce measurement burden, and increase the comparability of performance across different providers and settings, as well as the need for specialized measures to evaluate the quality of care appropriately for highly specialized practices. Medical specialty societies continue to develop quality measures, which have allowed many to participate in the Physician Quality Reporting System. However, many still find that numerous measures are inapplicable to their practice, which put them at risk for penalty.This issue must continue to be addressed as physicians cannot afford to be penalized for circumstances beyond their control. We are encouraged that MAP is keeping this in mind and working to find a solution. We also would like to take this opportunity to comment on measure PQI 92: Prevention Quality Chronic Composite and the sociodemographic factors that may have a significant impact on the outcomes addressed by this measure. SGIM agrees that adjustment for sociodemographic factors should be considered in measure development. Variations in patient need and the costs of care must be accounted for and are critical to ensure that providers who care for those patients most difficult to treat have a chance to succeed. For example, literacy and patient adherence to treatment recommendations may be a better predictor of some quality performance measures than diagnosis or disease severity, but these sociodemographic factors are often not properly accounted for when developing measures. Providers who care for higher risk patients should not be penalized unfairly for poor outcomes attributable to higher risk or patient behavior over which they have no control. Social determinants of health significantly confound performance measures and should be considered when evaluating patient outcomes and quality measures. Accounting for these factors will ensure a more accurate and equitable measure set for providers as they seek to provide the best care possible for their patient populations. Investigating and studying these factors that confound quality measures will help both MAP and healthcare providers moving forward. Addressing this issue will also safeguard against providers altering their patient population in order to increase their chance of success in these new payment schemes. Again, thank you for the opportunity to comment on this important work. If you have any questions, please do not hesitate to contact Erika Miller, at emiller@dc-crd.com or 202.484.1100. Sincerely, Eileen E. Reynolds, MD SGIM President (Submitted by: Society of General Internal Medicine)

General
  • We continue to support the MAP’s effort to align measure use across federal programs and urge NQF and the MAP to take into account efforts such as the Core Quality Measures Collaborative to ensure that measures recommended for public programs align with the private sector where appropriate. Comments specific to the Hospital Workgroup: We are supportive of the MAP’s recommendations in the Hospitals workgroup draft report. Comments specific to the Clinician Workgroup: We are supportive of the MAP’s recommendations in the Clinician workgroup draft report. (Submitted by: America's Health Insurance Plans)

  • The Association of American Medical Colleges (AAMC or Association) welcomes this opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership (MAP)’s 2017 Considerations for Implementing Measures in Federal Programs draft report. The AAMC is a not-for-profit association representing all 147 accredited U.S. medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and more than 80 academic and scientific societies. Through these institutions and organizations, the AAMC represents 160,000 faculty members, 83,000 medical students, and 115,000 resident physicians. The AAMC appreciates the MAP Workgroups’ thoughtful review and discussion of the measures under consideration (MUC). The following are the AAMC’s high-level comments on the MAP recommendations and the MAP review process for both hospitals and clinicians: • All Hospital Measures Reviewed by the MAP Hospital Workgroup Should be NQF Endorsed NQF endorsement demonstrates that a measure has been tested, is reliable, and can be used in a specific setting. With the volume of measures the MAP has to review, the Workgroups and Coordinating Committee rely heavily on NQF endorsement to ensure the measure is sound. Since hospital measures are typically not re-reviewed by the Workgroup, it is essential that these measures be NQF-endorsed at the time of consideration so that members are fully informed as to the measure’s appropriateness for the Medicare reporting and performance programs. The AAMC recommends that the NQF staff clearly state whether a measure is NQF endorsed in its materials to the Workgroup before the start of the discussion. The Association also strongly supports the Workgroup’s recommendation that “measures in the IQR set [particularly the episode payment measures] that have not been reviewed by NQF be submitted for endorsement review.” • Support Continued Development for PRO-PMs; Measures Should Not Be Used in Accountability Programs at this Time AAMC supports continued development and further MAP discussion of patient reported outcome performance measures (PRO-PMs). PROs are a critical tool for patients and providers to assess patient-reported health status for physical, mental, and social well-being. That being said, PRO-PMs are still in the early stages of development and therefore should not be included in reporting or accountability programs at this time. As noted by the Workgroup, there are significant concerns regarding how the tools and scoring methodologies will be standardized across patient populations, how the tools will be risk-adjusted, and the considerable burden of administering these instruments for patients and providers. Comments specific to the Clinician Workgroup: The Association of American Medical Colleges (AAMC or Association) welcomes this opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership (MAP)’s 2017 Considerations for Implementing Measures in Federal Programs draft report. The AAMC is a not-for-profit association representing all 147 accredited U.S. medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and more than 80 academic and scientific societies. Through these institutions and organizations, the AAMC represents 160,000 faculty members, 83,000 medical students, and 115,000 resident physicians. The AAMC appreciates the MAP Workgroups’ thoughtful review and discussion of the measures under consideration (MUC). The following are the AAMC’s high-level comments on the MAP recommendations and the MAP review process for clinicians: • Support Continued Development for PRO-PMs; Measures Should Not Be Used in Accountability Programs at this Time AAMC supports continued development and further MAP discussion of patient reported outcome performance measures (PRO-PMs). PROs are a critical tool for patients and providers to assess patient-reported health status for physical, mental, and social well-being. That being said, PRO-PMs are still in the early stages of development and therefore should not be included in reporting or accountability programs at this time. As noted by the Workgroup, there are significant concerns regarding how the tools and scoring methodologies will be standardized across patient populations, how the tools will be risk-adjusted, and the considerable burden of administering these instruments for patients and providers. • Providers Should Not be Held Accountable for Activities Outside Their Control The AAMC agrees with the Workgroups’ preliminary recommendation that the Patient Panel Smoking Prevalence measure should not move forward for CMS consideration. While we support reduction in smoking prevalence, we question whether it is appropriate to hold providers accountable for activity that is largely outside of their control. In addition, it is unclear as to how this measure would be applied and adjusted to account for factors, such as age, race/ethnicity, education, socioeconomic status, and geographic region. Before any new measure is submitted for inclusion in quality programs, CMS and the MAP should ensure that the measure’s value added is greater than the burden required to collect and submit such data. • Accountability Measures Must be Adjusted for Sociodemographic Status The AAMC has long advocated for appropriate adjustment for sociodemographic status (SDS) factors for certain outcome measures The AAMC strongly supports a robust and transparent SDS trial period. The Association is very concerned that the issues and concerns regarding SDS raised by relevant steering committees, who are tasked with reviewing these measures, are not being sufficiently addressed. We ask that the SDS trial period be a priority for the MAP, NQF, and CMS in 2017. The AAMC also notes that there are several measures in the current performance programs which have not been SDS adjusted. We ask that MAP include a recommendation regarding the need to adjust the existing measures, and have the opportunity to review all measures for appropriateness in the performance programs after the SDS trial period has concluded. Thank you for consideration of these comments. For questions regarding the Clinician MAP comments, please contact Gayle Lee (galee@aamc.org, 202-741-6429). • Providers Should Not be Held Accountable for Activities Outside Their Control The AAMC agrees with the Workgroups’ preliminary recommendation that the Patient Panel Smoking Prevalence measure should not move forward for CMS consideration. While we support reduction in smoking prevalence, we question whether it is appropriate to hold providers accountable for activity that is largely outside of their control. In addition, it is unclear as to how this measure would be applied and adjusted to account for factors, such as age, race/ethnicity, education, socioeconomic status, and geographic region. Before any new measure is submitted for inclusion in quality programs, CMS and the MAP should ensure that the measure’s value added is greater than the burden required to collect and submit such data. • Accountability Measures Must be Adjusted for Sociodemographic Status The AAMC has long advocated for appropriate adjustment for sociodemographic status (SDS) factors for certain outcome measures The AAMC strongly supports a robust and transparent SDS trial period. The Association is very concerned that the issues and concerns regarding SDS raised by relevant steering committees, who are tasked with reviewing these measures, are not being sufficiently addressed. We ask that the SDS trial period be a priority for the MAP, NQF, and CMS in 2017. The AAMC also notes that there are several measures in the current performance programs which have not been SDS adjusted. We ask that MAP include a recommendation regarding the need to adjust the existing measures, and have the opportunity to review all measures for appropriateness in the performance programs after the SDS trial period has concluded. • Review New and Existing Measures in the Medicare Programs to Ensure Metrics Add Value The AAMC strongly supports the hospital Workgroup’s recommendation that “hospital measures that are topped out, have unintended consequences, have lost NQF endorsement, or are no longer aligned with the current evidence or the program’s goals be removed.” The AAMC believes that the MAP should ensure that new and existing measures add value, are useful for consumers, and promote alignment, while also considering the burden to reporting these measures for providers. The Association supports extending this criteria to electronic clinical quality measures (eCQMs), which should not be used in place of a chart abstracted measure that is topped-out. Thank you for consideration of these comments. For questions regarding the Clinician MAP comments, please contact Gayle Lee (galee@aamc.org, 202-741-6429), and for questions regarding the Hospital MAP comments, please contact Scott Wetzel (swetzel@aamc.org, 202-828-0495). (Submitted by: Association of American Medical Colleges (AAMC))

  • In general, we believe that all MAP workgroups should have placed a greater focus on addressing measure gaps in the current measure sets given several announced refinements to the pre-rulemaking deliberations process earlier in 2016. We anticipated more targeted recommendations from MAP on measures for removal and identification of measure gaps. We encourage MAP to assert a greater role in this process moving forward and recommend that the MAP Coordinating Committee address this issue when they meet in-person January 24 and 25 to finalize the recommendations. Comments specific to the Hospital Workgroup: • Boehringer Ingelheim (BI) appreciates the opportunity to submit comments to inform the MAP Hospital Workgroup’s review of existing measure sets, currently included in seven hospital and setting-specific programs. We would like to call to MAP’s attention the significant gaps in outcomes and care delivery measures, particularly for patients with multiple chronic conditions and patients receiving behavioral health care in the inpatient setting. We urge MAP to take a more active and targeted approach to addressing these existing gaps. • BI notes a particular absence in measures for individuals with comorbid diabetes and cardiovascular disease.[1]  According to a 2014 CMS report on Medicare/Medicaid dual-eligibles, 45% of patients who had a heart condition were also diagnosed with diabetes.[2] Similarly, cardiovascular disease accounts for 28% of the costs of treating diabetes and associated complications.[3] At a national level, the American Diabetes Association reports that in 2012, the total estimated direct medical costs for diabetes care was $176 billion. At this time no existing measure in use in any of the CMS quality reporting programs explicitly reports on identification or treatment of patients with these comorbid conditions. We encourage MAP to focus on addressing this important measure gap. • Along those lines, BI also notes a lack of measures focused specifically on outcomes related to cardiovascular mortality for individuals with comorbid diabetes and cardiovascular disease. Evidence shows that cardiovascular disease is highly prevalent in patients with diabetes, is associated with high rates of mortality, and is a source of high financial burden to patients, caregivers, and the health care system at large. This is especially evident in the diabetes patient population where incidence of myocardial infarction (MI) is eight times higher than the general population. Additionally, patients with diabetes are also 2.7 times more likely to experience death related to coronary heart disease with a prior MI. [4] Although this gap area was not discussed in the Hospital Workgroup draft report, it is crucial that more focus is placed on developing measures that help ensure patients receive care that comprehensively meets their needs, both during and beyond the hospital stay. • On a broader level, BI recognizes that gaps continue to exist in outcomes related to general approaches to medication use for the long-term management of chronic disease across a multitude of clinical areas, including but not limited to, mental health, chronic obstructive pulmonary disease (COPD), and diabetes. This is a particularly important gap area, as healthcare for patients with complex chronic and comorbid conditions extends beyond care received in one setting of care. Many patients with multiple chronic conditions see multiple providers across multiple settings of care. In a 2012 analysis, CMS identified that patients with comorbidities including asthma and COPD were associated with up to 7 times higher costs than the average spending for Medicare beneficiaries. Additionally, patients with comorbid chronic conditions such as asthma, diabetes or COPD consume a significantly higher portion of healthcare resources. [5] We therefore believe there is an immediate need for MAP to focus on assessing and making recommendations for measures that address this gap area across all care settings that can help ensure patients receive coordinated and continuous care, particularly since the majority of Medicare patients do suffer from co-occurring conditions. • BI notes a similar gap in measures for care and outcomes for behavioral health. Behavioral health care has historically been fragmented and siloed, despite clinical guidance indicating the need for integration of behavioral health services across settings of care. [6] This is further exacerbated by the significant gaps in quality that have been observed not only in the treatment and management of behavioral health at psychiatric facilities but also outside of traditional behavioral health settings such as acute, post-acute and ambulatory care. Currently, CMS’ Inpatient Quality Reporting (IQR) Program does not include any behavioral health measures despite clear evidence, including a 2006 Institute of Medicine (IOM) report, emphasizing the high prevalence, costs, patient and system burden of mental health disorders. [7] This inability to measure the quality of behavioral health care delivery seriously hinders efforts to identify and improve care that is not aligned with clinical guidance. [8] As such, BI supports the potential future inclusion of measures addressing appropriate treatment and care coordination for behavioral health conditions in the Hospital IQR program. BI specifically recommends inclusion of measures related to serious psychiatric behavioral health disorders such as schizophrenia and bipolar disorder. We therefore recommend that the MAP Coordinating Committee reconsider the Hospital Workgroup’s recommendation to “refine and resubmit prior to rulemaking” for MUC16-041: Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting, and instead provide conditional support pending NQF Endorsement. Beyond this measure, it is critical that the MAP Coordinating Committee continues to seek inclusion of existing measures in mental health as stakeholders continue to refine and seek additional measures. • Furthermore, BI believes it is important for CMS to consider adopting quality measures that assess the consistency and comprehensiveness of care provided to patients to ensure continuity of care across all care settings. Future measures should go beyond measures of readmissions and mortality and instead incentivize providers to improve quality of care and reduce costs by implementing more effective care transitions. [9] For instance, with regard to the Inpatient Psychiatric Facility Quality Reporting program, MUC16-048: Medication Continuation Following Inpatient Psychiatric Discharge and MUC16-049: Medication Reconciliation at Admission are examples of measures that, if adopted, will help inpatient facilities track and monitor how their patients with complex behavioral health treatment regimens are admitted and eventually discharged with continuous treatment information that can be handed off to the next provider and any relevant caregivers.  [1] American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. 2013; DC_122625. DOI:10.2337/dc12-2625. [2] Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees. Centers for Medicare & Medicaid Services. Published September, 2014. Accessed January 9, 2017. [3] Sander S, et al. Poster presented at American Academy of Managed Care Nexus; October 3-6, 2016; National Harbor, MD. [4] Juutilainen A, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects. Diabetes Care. 2005;28(12):2901-7. [5] Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. [6] Fontanella CA, Guada J, Phillips G. Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. Adm Policy Ment Health. 2014; 41(5):572-87. [7] Institute of Medicine. Improving the quality of health care for mental and substance-use conditions. Washington (DC): National Academies Press; 2006. [8] Pincus HA, Spaeth-Rublee B, Watkins KE. The Case For Measuring Quality In Mental Health And Substance Abuse Care. Health Aff. 2011; 30:4730-736. [9] Agency for Healthcare Research and Quality. Seamless Care: Safe Patient Transitions from Hospital to Home. NTIS 200520. . Published February 2005. Accessed June 10, 2016. Comments specific to the Clinician Workgroup: • BI commends the Clinician Workgroup in acknowledging both the need for inclusion of outcome measures in the Merit-based Incentive Payment System (MIPS) as well as the difficulty of developing such outcome measures targeted for the clinician setting. However, BI urges the MAP Coordinating Committee to continue working to address persistent gaps in quality measurement, particularly for patients with multiple chronic conditions as well as patients with behavioral health disorders, many of whom also suffer from comorbid chronic conditions. • BI notes a particular absence in measures for individuals with comorbid diabetes and cardiovascular disease. [1] According to a 2014 Centers for Medicare & Medicaid Services (CMS) report on Medicare/Medicaid dual-eligibles, 45% of patients who had a heart condition were also diagnosed with diabetes. [2] Similarly, cardiovascular disease accounts for 28% of the costs of treating diabetes and associated complications. [3] At a national level, the American Diabetes Association reports that in 2012, the total estimated direct medical costs for diabetes care was $176 billion. At this time no existing measure in use in any of the CMS quality reporting programs explicitly reports on identification or treatment of patients with these comorbid conditions. We therefore encourage MAP to focus on addressing this important measure gap. • Along those lines, BI also notes a lack of measures focused specifically on outcomes related to cardiovascular mortality for individuals with comorbid diabetes and cardiovascular disease. Evidence shows that cardiovascular disease is highly prevalent in patients with diabetes, is associated with high rates of mortality, and is a source of high financial burden to patients, caregivers, and the health care system at large. This is especially evident in the diabetes patient population where incidence of myocardial infarction (MI) is eight times higher than the general population. Additionally, patients with diabetes are also 2.7 times more likely to experience death related to coronary heart disease with a prior MI. [4] At this time no existing measure in use in quality reporting programs explicitly reports on identification or treatment of patients with these comorbid conditions. • On a broader level, BI recognizes that gaps continue to exist in outcomes related to general approaches to medication use for the long-term management of chronic disease across a multitude of clinical areas, including but not limited to, mental health, chronic obstructive pulmonary disease (COPD), and diabetes. In a 2012 analysis, CMS identified that patients with comorbidities including asthma and COPD were associated with up to 7 times higher costs than the average spending for Medicare beneficiaries. Additionally, patients with comorbid chronic conditions such as asthma, diabetes or COPD consume a significantly higher portion of healthcare resources. [5] BI believes there is an immediate need to emphasize the development and testing of measures that can help ensure care for these patients is continuous and not siloed, particularly since the majority of Medicare patients do suffer from co-occurring conditions. • BI notes a similar gap in measures focused on care and outcomes for behavioral health. Behavioral health care in the U.S. has historically been fragmented and siloed despite clinical guidance indicating the need for integration of behavioral health services across settings of care. [6] These challenges are further exacerbated by significant gaps in quality that have been observed in the treatment and management of behavioral health. Despite expansion of services in behavioral health by CMS under the recent Medicare Physician Fee Schedule, measure gaps in this area still exist, especially with regard care coordination and medication management of complex treatment regimens. These issues are particularly relevant to this patient population, as many individuals with behavioral health disorders also suffer from comorbidities; it is estimated that over 90% of individuals with schizophrenia have a comorbid condition. [7]  [1] American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. 2013; DC_122625. DOI:10.2337/dc12-2625. [2] Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees. Centers for Medicare & Medicaid Services. Published September, 2014. Accessed January 9, 2017. [3] Sander S, et al. Poster presented at American Academy of Managed Care Nexus; October 3-6, 2016; National Harbor, MD. [4] Juutilainen A, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects. Diabetes Care. 2005;28(12):2901-7. [5] Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. [6] Fontanella CA, Guada J, Phillips G. Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. Adm Policy Ment Health. 2014; 41(5):572-87. [7] National Council for Community Behavioral Healthcare. Advancing Standards of Care for People with Schizophrenia. Available at:http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Advancing-Care-for-Schizophrenia-Final-Report-1.pdf Comments specific to the PAC/LTC Workgroup: • BI appreciates the opportunity to submit comments to inform the Post-Acute Care/Long-Term Care (PAC/LTC) Workgroup’s review of existing measure sets. However, BI urges the MAP Coordinating Committee to continue working to address persistent quality measure gaps, particularly with regard to patients with multiple chronic conditions and in with regard to care delivery and patient outcomes in the behavioral health space. We agree with the PAC/LTC workgroup’s acknowledgement in the draft report on the need to closely review existing measures in the Home Health Reporting Program (HHRP) and remove measures that may be “topped out” to ensure that measures in the program are addressing important care and outcomes issues, and to help minimize reporting burden on providers. We also appreciate the workgroup’s acknowledgement that gaps exist in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), however, we also urge MAP to take advantage of these opportunities and make meaningful recommendations to address these measure gaps. Specifically, older adult Medicare patients, who face a higher prevalence of comorbid conditions, are also the most frequent users of post-acute care services. Complex treatment protocols for this patient population are continued by post-acute care providers after discharge from the inpatient setting.  • BI notes a particular absence in measures for individuals with comorbid diabetes and cardiovascular disease. [1] According to a 2014 Centers for Medicare & Medicaid Services (CMS) report on Medicare/Medicaid dual-eligibles, 45% of patients who had a heart condition were also diagnosed with diabetes. [2] Similarly, cardiovascular disease accounts for 28% of the costs of treating diabetes and associated complications. [3] At a national level, the American Diabetes Association reports that in 2012, the total estimated direct medical costs for diabetes care was $176 billion. At this time no existing measure in use in any of the CMS quality reporting programs explicitly reports on identification or treatment of patients with these comorbid conditions. We therefore encourage MAP to focus on addressing this important measure gap. • Along those lines, there is also a lack of measures focused specifically on outcomes related to cardiovascular mortality for individuals with comorbid diabetes and cardiovascular disease. Evidence shows that cardiovascular disease is highly prevalent in patients with diabetes, is associated with high rates of mortality, and is a source of high financial burden to patients, caregivers, and the health care system at large. This is especially evident in the diabetes patient population where incidence of myocardial infarction (MI) is eight times higher than the general population. Additionally, patients with diabetes are also 2.7 times more likely to experience death related to coronary heart disease with a prior MI. [4] At this time no existing measure in use in quality reporting programs explicitly reports on identification or treatment of this high-burden yet vulnerable patient population. Therefore, BI believes it is important for CMS to consider adopting quality measures that assess continuity and long-term management of multiple chronic conditions, and for particularly for patients who comorbid with diabetes and cardiovascular disease, in post-acute and long-term care settings. • On a broader level, BI recognizes that gaps continue to exist in outcomes related to general approaches to medication use for the long-term management of chronic disease across a multitude of clinical areas, including but not limited to, mental health, chronic obstructive pulmonary disease (COPD), and diabetes. This is a particularly important gap area, as healthcare for patients with complex chronic and comorbid conditions extends beyond care received in a facility and has post-discharge implications in post-acute care settings. In a 2012 analysis, CMS identified that patients with comorbidities including asthma and COPD were associated with up to 7 times higher costs than the average spending for Medicare beneficiaries. Additionally, patients with comorbid chronic conditions such as asthma, diabetes or COPD consume a significantly higher portion of healthcare resources. [5] BI therefore believes there is an immediate need to emphasize the development and testing of measures that can help ensure care for these patients is continuous and not siloed, particularly since the majority of Medicare patients do suffer from co-occurring conditions. • Similarly, BI also recommends the PAC/LTC Workgroup highlight in its report the gaps in care-related care coordination and medication management of complex treatment regimens for behavioral health care. Patients with mental health conditions are more likely to also suffer from a comorbid health condition such as diabetes, stroke or lung disease. [6] Over 90% of individuals with schizophrenia are estimated to have a comorbid condition. [7] As stated in previous comments, patients with comorbidities often require several care providers across multiple care settings as well as complex medication regimens, which need to be monitored closely. As such, future measures should go beyond measures of readmissions and mortality and instead incentivize providers to improve quality of care and reduce costs by implementing more effective care transitions. [8] For instance, MUC16-048: Medication Continuation Following Inpatient Psychiatric Discharge and MUC16-049: Medication Reconciliation at Admission are examples of measures under consideration for the Inpatient Psychiatric Facility Quality Reporting program,  that, if adopted, will help inpatient facilities track and monitor how their patients with complex behavioral health treatment regimens are admitted and eventually discharged with continuous treatment information that can be handed off to the next provider and any relevant caregivers. BI supports the adoption of such measures in not only the inpatient setting, but also in post-acute and long-term care settings, such as in the HHRP and SNF QRP. Continuing to break down the barrier between physical and mental health is an important step to creating cohesive patient care in today’s healthcare system. Therefore, as the science of measurement advances, MAP should prioritize how best to comprehensively assess performance on these important quality improvement targets.  [1] American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. 2013; DC_122625. DOI:10.2337/dc12-2625. [2] Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees. Centers for Medicare & Medicaid Services. Published September, 2014. Accessed January 9, 2017. [3] Sander S, et al. Poster presented at American Academy of Managed Care Nexus; October 3-6, 2016; National Harbor, MD. [4] Juutilainen A, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects. Diabetes Care. 2005;28(12):2901-7. [5] Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. [6] Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees. Centers for Medicare & Medicaid Services. Published September, 2014. Accessed January 9, 2017 [7] National Council for Community Behavioral Healthcare. Advancing Standards of Care for People with Schizophrenia. Available at:http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Advancing-Care-for-Schizophrenia-Final-Report-1.pdf. [8] Agency for Healthcare Research and Quality. Seamless Care: Safe Patient Transitions from Hospital to Home. NTIS 200520. Published February 2005. Accessed June 10, 2016. (Submitted by: Boehringer Ingelheim)

  • Community Catalyst respectfully submits the following comments to the National Quality Forum (NQF) in response to the 2017 draft report of the Measure Application Partnership (MAP) workgroups regarding measures that are under consideration, particularly as they pertain to the dual eligible population. We appreciate the efforts that NQF and MAP workgroups have undertaken to put forth meaningful quality measures. However, we are disappointed that the package of measures does little to address the serious gaps that have been identified in each of the MAP workgroup draft reports. Of the priority gap areas identified, we want to strongly reinforce the importance of investment and development of measures in the following areas: patient experience and patient-reported outcomes, autonomy/self-determination and patient and caregiver goals. Patient Experience It is critically important to understand whether all of our efforts to improve health care are actually making a difference for patients. We would like to see measures based on patient-reported outcomes (PROs) that ask patients about the difference the care they received made in their lives. We also support measures of patient experience, engagement and activation. Finally, we note the value of collecting elicited patient narratives which allow patients to describe encounters with clinicians in their own words. Autonomy/Self-Determination Community supports and services are critical to individuals to maintain a quality of life which encourages independence, enables meaningful participation in work, relationships and community activities, if desired, and makes it possible to live in one’s preferred setting. It is imperative that NQF continue to support and monitor the development of measures that will help collect, track and evaluate performance around connecting health care services and community supports and services, such as through patient-reported quality of life. Patient and Caregiver Goals Goal-driven measures focus on a patient's individual health goals within or across a variety of dimensions (e.g., symptoms; physical functional status, including mobility; and social and role functions) and determine how well these goals are being met. A goal-driven approach has many advantages: o It frames the patient-provider discussion in terms of individually desired rather than universally applied health states. o It simplifies decision-making for patients with multiple conditions by focusing on outcomes that span conditions and aligning treatments toward common goals. o It prompts patients to prioritize which health states are important to them, thus allowing them to be in control when treatment options require trade-offs. o It allows for effective shared decision-making between patient and provider about which treatment strategies will meet the patient’s goals. Reducing Disparities In addition to the priority gap areas noted above, we believe that the MAP’s interest in addressing health disparities in the dual eligible population is important. The MAP should review its recommendations for measures under consideration to take into account whether these measures will help detect and address disparities. Please do not hesitate to contact me at ahwang@communitycatalyst.org with any questions. Thank you for your time and attention to these issues. Respectfully submitted, Ann Hwang, MD Director, Center for Consumer Engagement in Health Innovation (Submitted by: Community Catalyst)

  • General comment-We were concerned that no measures were approved for either hospital acquired conditions or hospital readmissions per Appendix C. Although hospital readmissions are down this year, data indicates that 30% of pediatric readmissions are preventable (source: https://pediatrics.aappublications.org/content/early/2016/07/20/peds.2015-4182). Hospital acquired conditions data has improved as CMS notes “across the FY 2015 and FY 2016 programs, the average performance across eligible hospitals improved on two of the three measures included in both program years” (source: https://www.acep.org/Clinical---Practice-Management/Health-Care-Acquired---Provider-Preventable-Conditions-FAQ/.) Nevertheless, there is increasing awareness of “superbugs” and most hospital acquired infections by their very nature are preventable. Addressing this will decrease costs and improve health care outcomes. (Submitted by: Family Voices NJ)

  • a) FLHCC supports the creation and use of measures that capture information related to appropriate use of health interventions and testing, and appropriate prescribing practices. b) FLHCC supports the needs for patient reported outcomes (PRO-PM) but is cautious. The concerns are as follows: a. Ability to capture the data accurately, timely, independently of the health care provider, and in the correct capacity of the patient. i. As an example, a PRO-PM might not be appropriate for measuring end of life care. Comments specific to the Hospital Workgroup: Page 5 – Balance Measurement Burden with Opportunity for Improvement FLHCC would like to see emphasis placed on electronic clinical quality measures (eCQMs). This type of data collection is less burdensome and the data is cleaner. Page 6 – Prospective Payment System – Exempt Cancer Hospitals….Paragraph 2 FLHCC supports the measure related to end-of-life care. Based on our research we agree that area needs improvement. Page 6 & 7 – Ambulatory Surgical Center Quality Reporting FLHCC would like to see facility and surgeon minimum procedure volume be incorporated. Page 10 – Hospital value based purchasing FLHCC would like to see PSI-90 replaced with the next generation BUT PSI-90 needs to stay until replaced. (Submitted by: Florida Health Care Coalition)

  • •For measures MUC16-031, -032, -033, -035, -036, -037, -039, and -040, we support these measures and believe it is feasible for Managed Care Organizations (MCOs) to report on them. However, the measures may have a higher likelihood of receiving complete surveys from family and caregivers than individuals. •For measure MUC16-296, -053, and -055, we support these measures and feel they are valuable; however, the measures’ hospital-based nature make them unfeasible for MCOs to report on. •For measure MUC16-176, we support this measure and feel it is valuable; however, if it were to become a process measure for MCOs, it would be unfeasible. •For measure MUC16-075, we strongly support this type of measure, but in the absence of being able to collect comprehensive lab data, this would be difficult to report and may result in falsely low reporting levels and outcomes. This is a more appropriate measure for hospitals and physicians. •For measures MUC16-087, -088, and -089, we support these measures but they would not be feasible for MCOs to report on. •For measures MUC16-151 and -312, these measures are appropriate for reporting at the physician level, not MCO. •For measure MUC16-317, case management and home-health screeners, in addition to the measure’s current mention of physicians, should be allowed to perform a documented safety screen within the parameters of this measure. We also recommend the use of a standardized tool. •For measure MUC16-142, we strongly support any efforts to reduce pressure sores and agree with the language included here that such sores are preventable and their impact on improved quality of life. •For measure MUC16-063, in Wisconsin we are required to report on those falls that required medical attention or follow-up. Though this does not solve for the self-report issue identified, it does provide more clarity to the individual around the expectation for reporting. (Submitted by: Magellan Health)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   NASS would also like to comment on some of the American College of Surgeons measures under consideration from the original 2016 MUC list. We question why MAP's preliminary decision for these measures was not included on the recommendation spreadsheet? Our comments are as follows:  MUC16-276- Preoperative Key Medications Review for Anticoagulation Medication (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients who take anticoagulation medication who are taken to the operating room for an elective intervention under regional anesthesia, monitored anesthesia care (MAC), and/or general anesthesia who have a peri-operative management plan for anticoagulation medications documented in the medical record.  - Goal of Measure: o While NASS appreciates that ACS has created measures that can be used by surgeons, we’re unsure that a check the box measure will translate into better care, such as different/improved VTE management. While the process itself may be a good thing, creating a checkbox mechanism for an administrative function leads to checkbox fatigue and potential gaming of the system.  These types of measures typically top-out quickly as providers learn to just check that box every time and then go on with the actual patient interaction. MUC16-278 - Patient Frailty Evaluation (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients age 80 and older who have been evaluated for frailty prior to an elective operation.  - Unit of Measurement: o What instrument will be used to assess frailty? - Goal of Measure: o Although NASS has no major concerns with this measure, we question the ultimate goal of the measure and how will it improve patient care? MUC16-279- Identification of Major Co-Morbid Medical Conditions (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients age 18 or older who are taken to the operating room for an elective surgical intervention under regional, and/or general anesthesia AND who have documentation of a significant co-morbid condition(s) in their medical record within 30 days of operation date.  - Measure Description: o How are co-morbid conditions defined? Is ASA class considered? - Data Acquisition and Entry: o NASS seeks clarification on the data logistics for this measure, including whether this will be an audit of a sample of records or will data fields need to be completed in a separate document? Will EHRs need to be configured? Is funding available for the additional technology and human resources required? MUC16-280- Intraoperative Timeout Safety Checklist (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients age 18 or older who are taken to the operating room for an elective or emergent surgical intervention under regional, MAC, and/or general anesthesia for whom an intraoperative safety checklist is performed prior to incision that includes the patient’s name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging.  - General Comments: o NASS questions whether specific checklists are required or will the type of checklist be left up to the discretion of the surgeon/administrator? NASS cautions the use of a “one size fits all” checklist as it would not be appropriate for all surgeries and patient populations. There are many surgical checklists that are specific to surgery, specialty and patient population; therefore, we recommend that the decision to use a particular checklist is left up to the surgeon/administrator. - Measure Description: o NASS recommends that eligible procedures are more specifically defined.  Spinal injection procedures, although used with anesthesia, should not be subjected to the same checklist as surgical procedures. While a reliable checklist system should be in place for both, the patient flows and needs are different for each. - Goal of Measure: o While NASS appreciates that ACS has created measures that can be used by surgeons, we’re cautious about tying checkbox measures to improved patient care. While the process itself may be a good thing, creating a checkbox mechanism for an administrative function leads to checkbox fatigue and potential gaming of the system.  These types of measures typically top-out quickly as providers learn to just check that box every time and then go on with the actual patient interaction. MUC16-281- Postoperative Care Coordination and Follow-up with Primary/Referring Provider (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients age 18 or older who are taken to the operating room for an elective or emergent surgical intervention under regional, MAC, and/or general anesthesia who had documented post-operative communication regarding the surgery with the patient’s primary care physician or referring physician within the 30 days following surgery. - Goal of Measure: o NASS supports measures that aim to improve care coordination. NASS seeks clarification regarding how communication will be assessed? Are resources available for the additional costs incurred, including opportunity costs from slowing down clinical efficiency with administrative burden? MUC16-285 - Unplanned Hospital Readmission within 30 Days of Principal Procedure: Percentage of patients age 18 or older who had an unplanned hospital readmission within 30 days of principal procedure - General Comments: o This type of measure is already being used in other public reporting programs. How will competing measures be reconciled? MUC16-286- Participation in a National Risk-adjusted Outcomes Surgical Registry (Group measure as defined by Am. Coll. of Surgeons): This measure requires participation in at least one multi-center, standardized national data collection and feedback program that provides benchmarking relative to national data and uses process and/or outcome measures. This measure requires a “yes” or “no” response to whether a facility, program, or individual surgeon participates in a national risk-adjusted outcomes surgical registry.  - General Comments: o While NASS agrees with the measure concept, we do want to highlight that there is great variability in the availability and quality of registries across surgical specialties. Additionally, participation in some surgical registries is cost prohibitive. How will these factors be considered? MUC16-288 S- Surgical Plan and Goals of Care (Preoperative Phase) (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients who have been given the purpose for the recommended procedure AND goals of care discussion has been documented in the medical record.  - Data Acquisition and Entry: o NASS questions the feasibility of this measure. The outlined categories of purposes and goals are presently not available in EHR systems. It is unclear how human and IT resources will need to change to accommodate this template and how these changes will be funded. MUC16-293- Patient-Centered Surgical Risk Assessment and Communication (Group measure as defined by Am. Coll. of Surgeons): Percentage of patients age 18 or older who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with a surgeon  - Measure Numerator: o While NASS supports risk assessment of patients prior to surgical procedures, the measure is vague. Regarding the use of a validated risk calculator, are there specified calculators that have to be used or is use of a particular calculator left up to the discretion of the surgeon/administrator? (Submitted by: North American Spine Society)

  • PhRMA appreciates the MAP’s ongoing work to review and prioritize measures for inclusion in federal health care programs. As CMS refines existing programs and implements new quality reporting requirements, such as the IMPACT Act and the Merit-Based Incentive Payment System (MIPS), the MAP process provides an important opportunity for stakeholder input into the measures under consideration as well as CMS’ programmatic goals and needs. In 2016, MAP announced several refinements to the pre-rulemaking deliberations, including that measure sets would be reviewed holistically, allowing MAP to make recommendations on current measure sets to include recommendations for measure removal and identification of measure gaps. PhRMA understood that this would be an important, new scope of work for MAP in the 2016-2017 pre-rulemaking cycle; however, it appears that holistic review of measure sets received only limited attention in MAP’s draft reports. The holistic review of program measure sets is increasingly important as CMS works to align measures for meaningful quality improvement while balancing measurement burden for providers. As a multi-stakeholder body with considerable expertise in quality measurement and improvement, MAP is well positioned to evaluate and make comprehensive recommendations to CMS about the future direction of program measure sets. We encourage MAP to assert a greater role in this process moving forward. PhRMA appreciates acknowledgement by the MAP work groups that patient centered measures are critical to assessing quality of care, driving quality improvement, and generating actionable data for health care providers and patients and so must continue to be a priority. Yet, as the MAP work groups noted in their deliberations, significant gaps persist in the availability and use of patient-centered measures, particularly measures of patient-reported outcomes, functional status, care coordination, and measures that incorporate patient values and preferences. Identifying these gaps and working with measure developers and other stakeholders to address them must continue to be a high priority. For some conditions, patient-reported outcome measures (PROMs) are available but are not yet in broad use. In addition to identifying measure gaps, MAP should consider mechanisms to encourage broader adoption of valid, evidence-based PROMs. A 2015 white paper from Avalere Health recommended provisional adoption of PRO performance measures (PRO-PMs) in pay-for-reporting and accreditation programs as one strategy to increase use of PRO-PMs. Structural measures, such as MUC 16-393: PRO Utilization in Non-Metastatic Prostate Cancer Patients, which measures use of evidence-based, valid PROMs can serve as an “on-ramp” or interim step to PRO measurement through PRO-PMs. Comments specific to the Hospital Workgroup: MAP issued a recommendation to refine and resubmit MUC 16-263: Communication about Pain – Composite Measure because it is at an early stage of testing and results have not yet been published. In 2016, CMS finalized rules for the Hospital Value Based Purchasing Program (HVBP) that removed the HCAHPS Pain Management composite in response to concerns that the Pain Management dimension questions may create pressure on hospital staff to prescribe more opioids in order to achieve higher scores on this dimension. MAP's recommendation of "refine and resubmit" will result in a greater implementation lag for filling the pain management measure gap in the HVBP. We agree with MAP that filling measure gaps must always be balanced with the need for measures to be reliable and valid prior to their use in pay for performance programs. In the interim, it will be important for CMS to perform regular assessments to ensure there are no unintended or inappropriate consequences on legitimate patient access to needed medicines. Comments specific to the Clinician Workgroup: In 2016, MAP announced that it would review measure sets holistically, allowing the MAP to make recommendations on current measure sets to include recommendations for measure removal and identification of measure gaps. PhRMA agrees that the holistic review of measure sets is important to ensure use of high value measures and fill measure gaps while balancing measurement burden for providers. Holistic review of the Merit-Based Incentive Program measure set is complicated by the multiple pathways for reporting under the program. Though they are required to be publically listed, many measures reported through qualified clinical data registries (QCDRs) are not submitted as part of the MAP pre-rulemaking process, nor are they specifically identified in the annual Medicare Physician Fee Schedule rules. PhRMA recommends that future MAP reviews include the full listing of MIPS measures, including those reported through QCDRs, to provide the MAP with a more complete picture of the program measure set and aid MAP in identifying gaps and promoting measure alignment. (Submitted by: PhRMA)

  • On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, and our 43,000 individual members, the American Hospital Association (AHA) appreciates the opportunity to comment on the Measure Applications Partnership’s (MAP) December 2016 pre-rulemaking draft recommendations. This letter provides overarching comments about the MAP process; we commented separately on specific measures under review using the National Quality Forum’s (NQF) online commenting tool. The AHA continues to believe the MAP’s best opportunity to promote broad improvement in health care is to use a streamlined set of actionable quality improvement priorities to identify “measures that matter” the most to optimizing outcomes for patients and communities. By leveraging its multi-stakeholder composition and mandate to review measures across nearly all of the Centers for Medicare & Medicaid Services’ (CMS) programs, the MAP is in the unique position to accelerate improvement by recommending a limited number of effective, reliable and care setting-appropriate measures. Currently, the field is inundated with uncoordinated measure requirements from a variety of public and private payers. The AHA stands ready to work with the MAP to identify system-wide priorities upon which the MAP could evaluate measures and CMS could identify potential future measures. Using input from hospital leaders, the AHA has identified 11 quality measurement priority areas (Attachment A) for hospitals. Those areas also are well-aligned with the 15 core measure areas for the nation’s health care system identified in the National Academy of Medicine’s (NAM) Vital Signs report. In our Jan. 12, 2016 letter, the AHA recommended the MAP use these areas to evaluate measures and quality improvement. A mapping of AHA hospital measurement priorities to NAM core measures is provided in Attachment B. Unfortunately, the MAP process has yet to realize the promise of identifying “measures that matter.” As a result, the MAP considers and often supports an excessive number of measures unmoored to any priority areas and lacking evidence demonstrating that their use will enhance the quality of care. Below the AHA recommends additional steps the MAP should take to ensure the measures it recommends most effectively enhance quality improvement efforts for patients. The AHA urges the MAP not to recommend any new measures that duplicate data efforts or data produced by existing processes. Many of the measures on this year’s Measures under Consideration (MUC) list would duplicate efforts or data produced by existing processes. For example, several measures involve performing an additional examination or screening upon admission to evaluate a specific condition, such as malnutrition or alcohol/substance abuse. Providers already perform tests and screenings at intake that provide more than enough information to make judgments on whether a patient suffers from those specific conditions. The additional screening mandated by the measure could be entirely inconsistent with existing workflow, thereby increasing the workload without improving the value to the patient. Moreover, these process measures often do no more than assess whether a provider completed a task. The measures do not demonstrate a strong connection between the process step taken and improved patient outcomes. This is problematic for two reasons. First, process measures unlinked to better outcomes can drive provider efforts towards narrow interventions rather than holistic care. For example, a malnutrition screening measure could replace the existing and more robust intake process for an overworked provider. If it is easier to perform a cursory malnutrition screening as required by the measure, there is no need to perform other important tests and screenings upon admission that do not contribute to quality scores. Second, these process measures add a significant number of tasks; even if they are not duplicative, process measures often entail substantial effort to collect. Therefore, the AHA suggests that the MAP should only recommend process measures if they show a strong correlation between the measured intervention and outcomes of interest. In addition, the AHA is concerned that many measures have been insufficiently tested and validated to ensure that they will produce useful and accurate data at the relevant sites of care. Without that information, it is very challenging to even suggest something be “refined and resubmitted” because there is not enough information to know whether the measure can actually work in its current form. For example, certain measures require post-admission follow-up visits with patients, which the AHA acknowledges are important parts of the care continuum. However, the measures as they were specified for the MAP were tested at the health plan level, not for acute care hospitals. Many other measures discussed at the MAP workgroup meetings did not have NQF endorsement at the time, or explicitly did not meet the evidentiary standards required. Untested or non-evidence-based measures are inappropriate for consideration by the MAP; therefore, the AHA suggests that CMS only include fully tested and NQF-endorsed measures on the MUC list. Putting forth a concept of a measure rather than a fully developed, specified and tested measure for MAP review is inconsistent with the congressional intent that created the MAP. We appreciate CMS’s interest in obtaining the input of the MAP on measure concepts or ideas; however, we believe that task should not occur simultaneously with the review of measures being proposed for inclusion in a program. Furthermore, the AHA cautions the MAP against a hierarchical preference for electronic clinical quality measures (eCQMs). The AHA continues to be concerned about the burden of reporting eCQMs. During the MAP hospital workgroup discussions, many participants appeared to suggest that eCQMs are unequivocally easier to collect and report than chart-abstracted measures. While theoretically these measures should reduce the effort entailed in manual chart abstraction, introducing additional or converting existing measures to be eCQMs incorrectly assumes that the measures work as intended and that all electronic health record (EHR) products support the reporting of those measures. A 2013 AHA study of the experiences of hospitals in reporting eCQMs revealed that measure specifications are often not truly “plug and play,” and hospitals must employ extensive workarounds to obtain measure results. Moreover, hospitals often obtain measure results from eCQMs that do not correlate with the results from the gold standard chart abstracted measures. In addition, many of the quality reporting programs discussed at the MAP workgroup involved sites of care that are not required to or typically do not have fully interoperable EHR systems (e.g., freestanding inpatient psychiatric facilities or end-stage renal disease facilities). Because of questions concerning the feasibility and accuracy of eCQMs, the AHA urges restraint in adding or converting measures into eCQMs.  Finally, this year’s MAP considered measures regarding major public health issues such as opioid abuse and malnutrition. While the AHA acknowledges the importance of treating patients suffering from these maladies, the measures proposed provided virtually no data demonstrating the connection between the measure and improved patient outcomes. Some measures even evaluated hospital performance based on community-level outcomes without a mechanism to accurately attribute the health of the patient population to hospital efforts. For example, a community smoking prevalence measure is a great measure for a public health department or Medicaid program. But given the multitude of factors contributing to smoking rates, it would be more appropriate to assess hospitals on their efforts to improve on the outcome, not on the overall outcome. The AHA urges CMS not to include such measures for consideration unless there is evidence linking the intervention to improved outcomes. Thank you for the opportunity to comment. Please contact me if you have questions or feel free to have a member of your team contact Caitlin Gillooley, associate director of policy, atcgillooley@aha.org or (202) 626-2267. Sincerely, /s/ Ashley Thompson Senior Vice President Public Policy Analysis and Development Attachment A AHA Identified Priority Measurement Areas 1. Patient Safety Outcomes • Harm Rates • Infection Rates • Medication Errors 2. Readmission Rates 3. Risk Adjusted Mortality 4. Effective Patient Transitions 5. Diabetes Control 6. Obesity 7.  Adherence to Guidelines for Commonly Overused Procedures 8.  End of Life Care According to Preferences 9.  Cost per Case or Episode of Care 10. Behavioral Health 11. Patient Experience of Care / Patient Reported Outcomes of Care Attachment B Mapping of AHA Hospital Measure Priority Areas to the National Academy of Medicine’s Vital Signs Core Measure Areas Life Expectancy     Risk Adjusted Mortality (#3) Wellbeing      Diabetes Control (#5) Overweight & Obesity      Obesity (#6) Addictive Behavior      Behavioral Health (#10) Unintended Pregnancy Healthy Communities Preventive Services Care Access     Readmission Rates     Effective Patient Transitions Patient Safety     Patient Safety Outcomes (#1) • Harm Rates • Infection Rates • Medication Errors Evidence-based Care     Adherence to Guidelines for Commonly Overused Procedures (#7) Care Matched to Patient Goals      End of Life Preferences (#8) Personal Spending Population Spending     Cost Per Case of Episode (#9) Individual Engagement     Patient Experience of Care/Patient-Reported Outcomes (#11) Community Engagement (Submitted by: The American Hospital Association)

General
  • On behalf of our nearly 300 member hospitals, dedicated to high-quality care for all, including the most vulnerable, and providing a disproportionate share of the nation’s uncompensated care, America’s Essential Hospitals appreciates the opportunity to comment on the Measure Applications Partnership (MAP) 2017 Considerations for Implementing Measures in Federal Programs: Hospitals, draft report. We respectfully submit our comments on the measures under consideration (MUC) list to the MAP for consideration during this pre-rulemaking process. Risk Adjustment With more than a third of the measures included in the preliminary report being outcomes measures, it is important that the MAP appropriately assess these measures for the impact of sociodemographic factors, including socioeconomic status, and risk adjust if warranted. Without proper risk adjustment, an essential hospital that serves many of the most complex patients, who also have low incomes and other confounding sociodemographic factors, might appear through public reporting to have poorer outcomes than other hospitals. But this is an inaccurate and misleading picture created by factors outside the control of the hospital and its providers. We would like to highlight and support the comments raised by the Hospital Workgroup on recent passage of 21st Century Cures—legislation to risk adjust quality reporting for socioeconomic status by requiring the Secretary of the Department of Health and Human Services to implement a transitional risk adjustment methodology to serve as a proxy of socioeconomic status for the hospital readmissions reduction program. We agree with Workgroup members that CMS should explore ways to align the readmissions measures across all programs and address social risk factors in both measure development and rulemaking. Further, we support the Workgroup’s recommendation related to the Assistant Secretary for Planning and Evaluation’s (ASPE) report to Congress, which called for better risk adjustment for social risk factors that make it harder for some patients to achieve good outcomes, and for which essential hospitals are penalized at a higher rate than other hospitals, for reasons beyond the control of the hospital. We support the ASPE report’s call for continued study of all measures to improve their ability to fairly and accurately assess provider performance, and agree with the Workgroup’s recommendation that CMS consider the work of ASPE in its value-based purchasing programs. Pain Management Measures America’s Essential Hospitals understands that patient-centered care improves patient outcomes and satisfaction. CMS implemented the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey as one method of formally recognizing that patient experience is central to health care. It is important that CMS continuously monitor and refine the questions contained in the HCAHPS survey to avoid any unintended consequences and ensure that the right questions are being asked. After concern was raised that patient satisfaction questions related to pain management might set unrealistic expectations regarding medications for pain relief, and may lead to dissatisfaction with care when those expectations are not met, CMS finalized the removal of such questions for payment purposes under the hospital Value-based Purchasing (VBP) Program in FY 2018. We agree with the MAP preliminary decision to refine and resubmit the pain measures under consideration (MUC16-263 and MUC16-264), which would replace the current Pain Management measure in the HCAHPS survey. The measures assess pain management both during the hospital stay and post-discharge. However, these measures are still in the development and testing phase and not yet in use by hospitals. There is a real risk that these measures will induce the very behavior that was at the core of the recent removal of pain measures from the VBP program—i.e., the expectation that pain management should always include use of powerful prescription drugs such as opioids. We agree with the Workgroup members that the testing results of these new measures must demonstrate reliability and validity for the Inpatient Quality Reporting (IQR) program prior to inclusion. Further, the measures should be in the IQR for at least one year prior to adoption in the hospital value-based purchasing program. We encourage CMS to continue development of the new pain management measures, with input from stakeholders, to ensure the information collected accurately reflects patient experience in a meaningful way. Measure Alignment America’s Essential Hospitals supports the creation and use of a strategic, high impact set of quality metrics for use in Federal programs. We emphasize the importance of streamlining measures to promote greater alignment and harmonization and to reduce redundancies and inefficiencies. Measures should be used in programs only if they reveal meaningful differences in performance across providers. The measures should also be administratively simple to collect and report. Alignment—between hospitals, physicians, and others—should be the goal, across the care continuum, to reduce unnecessary data collection and reporting efforts. The MUC list contains several measures that lack a clear rationale for inclusion in the reporting programs, among them the Safe Use of Opioids–Concurrent Prescribing measure (MUC16-167). We agree with the Workgroup that this measure should not be included for rulemaking due to the existence of many clinical conditions where concurrent prescriptions of opioids are in fact appropriate. Additionally, related to the Measure of Quality of Informed Consent Documents (MUC16-262), it is difficult to determine whether or how this measure would contribute to a specific national goal for improvement, and whether it is the most effective in promoting achievement of the desired improvement. While informed consent is an important activity for which hospitals should develop meaningful documents and processes, we fail to see how a national measure of informed consent makes the consent process any better or more meaningful. We agree with the Workgroup comments that this measure should be revised and resubmitted prior to rulemaking as there is not only reporting burden associated with this measure, but also complexity of existing guidelines for hospitals—CMS Conditions of Participation, accrediting standards, state laws and regulations. We agree with the Workgroup’s recommendation to support the measure for alcohol screening (MUC16-179), as it relates to prevention of alcohol withdrawal syndrome, which can be life-threatening. We further agree with the Workgroup that the measure for alcohol use brief intervention (MUC16-178) should not be supported for rulemaking based on a lack of evidence demonstrating the impact of brief interventions on alcohol use and the administrative burden resulting from manual chart abstraction needed to implement this measure. (Submitted by: America's Essential Hospitals)

  • The draft report entitled “MAP 2017 Considerations for Implementing Measures in Federal Programs: Hospitals” includes additional recommendations for the ASCQR Program. Among these is the recommendation to remove 1) measures that have been in the program longer than two years and have not been submitted to the NQF for review and endorsement and 2) measures that are no longer NQF endorsed. We believe it is important to point out that NQF endorsement is not required by the Social Security Act for measures adopted for the ASCQR Program. CMS has repeatedly stated as much. In a recent example (see 81 FR 79808, November 14, 2016), CMS stated “…section 1833(t)(17)(C)(i) of the Act does not [emphasis added] require that each measure CMS adopts for the ASCQR Program be endorsed by a national consensus building entity, or the NQF specifically. Further, under section 1833(i)(7)(B) of the Act, section 1833(t)(17)(C)(i) of the Act applies to the ASCQR Program, except as the Secretary may otherwise provide. Under this provision, the Secretary has further authority to adopt non-endorsed measures. While we strive to adopt NQF-endorsed measures when possible, we believe the requirement that measures reflect consensus among affected parties can be achieved in other ways, including through the measure development process, through broad acceptance and use of the measure, and through public comments.” In addition, it should be understood that a lapse in NQF endorsement is not a criterion for removing measures from the ASCQR Program. We refer the MAP Hospital Workgroup to 42 CFR §416.320, for the complete list of criteria for removal of quality measures from the ASCQR Program. We remain concerned regarding the lack of ASC organizational or subject matter expert presence on the MAP Hospital Workgroup. These recommendations could have been avoided if the Workgroup included an ASC representative. We trust that corrections to the draft report will be made, and hope the lack of ASC representation that led to these misinformed recommendations will be rectified at the earliest opportunity. (Submitted by: ASC Quality Collaboration)

  • CAPC thanks the Hospital workgroup for the opportunity to review and comment on its draft report. We fully support the priorities identified in the subsection “Move to High-Value Measures” (p. 4), as these have implications for the care of seriously ill patients. In regards to the need for new and/or improved patient-reported outcome measures, it might be worth noting that any new measures should have some mechanism to account for instances in which patients’ illness progress to a point where they are unable to advocate for themselves (e.g., proxy reporting). Acknowledging the large number of competing priorities in new measure development, we also want to suggest a few other possible priority areas including care consistency with patient preferences for treatment, access to palliative care, and financial toxicity. In the discussion of considerations for the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) program (p. 6), we appreciate the workgroup’s support of four measures related to end-of-life (EOL) care and its general acknowledgement of EOL in cancer care as an area needing improvement. We want to note that although this discussion was in the context of the PCHQR, cancer is not the only disease that would benefit from improved attention in palliative care and EOL care. Therefore, we ask that the Hospital workgroup consider encouraging measure developers in other diseases to work on developing these measures. Finally, we appreciate the workgroup’s thoughtful deliberation and recommendations on measures #056 and #167 (p. 8), as well as #263 (p. 10). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • The March of Dimes, a unique collaboration of scientists, clinicians, parents, members of the business community, and other volunteers representing every state, the District of Columbia and Puerto Rico, urges the Measures Application Partnership (MAP) to consider adding to the Inpatient Quality Reporting (IQR) Program The Joint Commission’s Cesarean Birth perinatal care measure (PC-02), which tracks instances of nulliparous, term, singleton, vertex cesarean section procedures. The IQR plays an important and increasingly significant role in our nation’s health care system as institutions and providers work to shift to a focus on quality of care. The IQR provides a near-universal snapshot of hospitals’ performance on a range of key processes and outcomes. In its draft report, the MAP Hospital Workgroup emphasized the “need for measures that matter to most patients” in IQR and other programs. The March of Dimes believes that the PC-02 cesarean section measure represents precisely the type of measure that matters to many patients and families. The PC-02 measure provides valuable information to determine the extent to which hospitals are managing the lowest-risk pregnancies to prevent cesarean sections, which are a major surgical procedure. Inclusion of PC-02 is especially pertinent in light of the fact that women who undergo the procedure for one delivery are highly unlikely to give birth vaginally in subsequent deliveries, making this measure a strong indicator of future cesarean section rates. While the March of Dimes acknowledges fully that there is no consensus in the health care community on a “right” level of cesarean sections, IQR reporting would provide a full, publicly accessible picture of the variations among hospitals and important insights for consumers, researchers, and other stakeholders. The March of Dimes is a strong proponent of the reporting of The Joint Commission’s Elective Delivery (PC-01) measure, which has been utilized by payers and systems to decrease the rate of non-medically indicated inductions between 37 and 39 weeks of gestation for all patients, in the IQR and on the Hospital Compare website. Adding PC-02 reporting data for all patients would follow this precedent and allow health care consumers public access to transparent, longitudinal data to help them make decisions that best meet their and their family’s health care needs. (Submitted by: March of Dimes)

  • The National Partnership for Women & Families appreciates the opportunity to provide the following comments on the MAP Hospital Workgroup Draft Report. 1) We strongly support the request of the American College of Obstetricians and Gynecologists (ACOG) for MAP to recommend adding the Cesarean Birth measure (NQF 0471) to the Inpatient Quality Reporting (IQR) Program. We applaud ACOG for this leadership, and note that because of the non-Medicare foundation for the proposed measure, this priority measure may not appear on the Measures Under Consideration list without external prompting. This request follows an established precedent: in 2013, hospitals began reporting The Joint Commission’s Elective Delivery (#0469) maternity measure to the IQR Program for all payers (not limited to Medicare). The Elective Delivery measure has had a major impact on the quality of maternal care and on perinatal outcomes. In their recently reaffirmed 2014 statement on Safe Prevention of the Primary Cesarean Delivery, ACOG and the Society for Maternal-Fetal Medicine conclude that the steep rise in the cesarean rate since the mid-1990s has not been associated with any discernible improvement in maternal and infant health. On the contrary, safely avoidable cesareans pose a broad range of excess shorter- and longer-term harms for women and cesarean-born babies. The statement also recommends many evidence-based practices for safely reducing the likelihood of cesarean birth. Cesarean Birth is a measure of a low-risk population that enables meaningful comparison across facilities. It is included in various measurement programs, such as The Joint Commission’s Perinatal Care Core Set (PC-02, now collected for accreditation of all facilities with 300 or more births per year), the MAP Medicaid Child Core Set, and the Core Quality Measures Collaborative Ob-Gyn Core Set. Healthy People 2020 objective MICH 7.1 uses a variant. Measuring and tracking cesarean rates in low-risk women is an important step for improving maternal and infant health through public reporting and other mechanisms. As ACOG notes in their comments, The Joint Commission’s Cesarean Birth all-payer measure is ready for implementation and would nicely complement the all-payer Elective Delivery measure now in use in IQR. Further, The Joint Commission is developing an e-measure of PC-02 to expand collection options. As demonstrated during the Hospital Workgroup’s 2015 discussion, a perinatal measure is unlikely to be useful for a Medicare-only population (e.g., the VBAC measure considered and not recommended due to reliance on Medicare claims alone). However, an all-payer IQR measure that captures rates of this overused intervention among all births would provide valuable information about hospitals’ maternity care quality. We hope this information will soon be available to help women and families make informed choices about where to give birth. 2) We strongly support the emphasis on patient-reported outcome measures (PROMs) as a high priority target for measures within CMS’s programs. PROMs reflect issues that are important to patients and provide a valuable perspective – such as severity of pain and physical functioning – that cannot be obtained from other data sources. They complement, and do not replace, clinical outcomes. When embedded in systematic care processes, PROMs open up new opportunities for patient engagement, care management, and performance improvement. 3) Members of the MAP Hospital Workgroup indicated support for continued development of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures measure. We feel this sentiment is not adequately captured in the final report. Shared decision making is a key component of patient-centered health care. It fosters clinician-patient partnerships in making decisions about care plans and specific tests and treatments. Patients who are informed and effective managers of their own health are more likely to experience improved patient satisfaction, improved clinical outcomes, and lower health care costs. Unfortunately, informed consent is often a perfunctory, last-minute process to address legal aspects of care. These cases represent missed opportunities for meaningfully engaging patients in their health care decisions and provide care that is well aligned with their values and preferences. Consumers are very supportive of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures measure. By assessing the quality of informed consent documents, this measure goes beyond a check-the-box process measure. The measure also represents an innovative approach to using the informed consent process as a vehicle for shared decision-making. Of note, this measure helps fill the cross-cutting measure gaps identified in the report. 4) We greatly appreciate that the Draft Report’s summary refers to the hospital workgroup’s discussion on considering the amount of effort required for measure collection in the context of the value of information obtained. Throughout, however, the report reverts back to highlighting effort outside of this context. We believe this should be rectified to align the full report with the summary and workgroup discussion. Frequently, the effort required of providers for measure collection is negatively characterized as a ‘burden’, particularly when the value of a measure is not taken into account. As we continue to strive for parsimonious, high-leverage measure sets, it is critical that the measurement effort on the part of the provider be weighed against the value of the information the measure furnishes. (Submitted by: National Partnership for Women & Families)

  • We believe the following are important measures:Pfizer supports measures 51 and 52 because we agree with CMS that tobacco use creates a heavy cost to society.  Smoking cessation measures can be related to reductions in AMI mortality measure (Bradley, JAMA).  We recommend that this measure should distinguish a light smoker as in the US PHS guidelines-- light is <10 cigarettes/day from others
  • The Society for Maternal-Fetal Medicine (SMFM) concurs with the American College of Obstetricians and Gynecologists (ACOG), in asking the Measures Application Partnership (MAP) and the Centers for Medicare and Medicaid Services to consider adding nulliparous, term, singleton, vertex cesarean sections as captured by The Joint Commission’s Cesarean Birth (PC-02) measure to the Inpatient Quality Reporting Program. The MAP Hospital Workgroup’s Draft Report emphasized a “need for measures that matter to most patients” (page 10); we believe that childbirth/perinatal care is a critical health care decision point for mothers and their families. Please note that because of the non-Medicare foundation for this measure, we do not expect this measure to present itself on the Measures Under Consideration list without external prompting.      Please note that hospitals began reporting non-medically indicated inductions between 37 and 39 weeks of gestation as captured by The Joint Commission’s Elective Delivery (PC-01) measure to the Inpatient Quality Reporting Program (and Hospital Compare website) in 2013 for all patients (not just for births paid by Medicare). Reporting for all nulliparous, term, singleton, vertex cesarean sections would follow an established precedent.  With January 1, 2014, discharges, The Joint Commission began requiring the Perinatal Care Core Set (which includes PC-01 and PC-02) measures to be reported for accreditation of facilities with 1,100 or more births annually. With January 1, 2016, discharges, The Joint Commission began requiring Perinatal Care Core Set measures to be reported for facilities with 300 or more births per year. Elective Delivery (PC-01) and Cesarean Birth (PC-02) have been included, respectively, in the voluntary Adult Medicaid Core Set and the Children’s Health Insurance Program Core Set since 2011. In the voluntary Child Core Set, measurement of Cesarean Birth (PC-02) has thus far only risen from 2 states in FFY2010 to 16 states in FFY2014. Both of these measures have been endorsed by the National Quality Forum since 2008, Elective Delivery (PC-01)’s e-specification was also recently endorsed in 2016.                (Submitted by: Society for Maternal-Fetal Medicine)

  • On behalf of the American College of Obstetricians and Gynecologists, a professional organization representing over 57,000 physicians and partners in women’s health, we ask the Measures Application Partnership (MAP) and the Centers for Medicare and Medicaid Services to consider adding nulliparous, term, singleton, vertex cesarean sections as captured by The Joint Commission’s Cesarean Birth (PC-02) measure to the Inpatient Quality Reporting Program. The MAP Hospital Workgroup’s Draft Report emphasized a “need for measures that matter to most patients” (page 10); we believe that childbirth/perinatal care is a critical health care decision point for mothers and their families. Please note that because of the non-Medicare foundation for this measure, we do not expect this measure to present itself on the Measures Under Consideration list without external prompting.     Please note that hospitals began reporting non-medically indicated inductions between 37 and 39 weeks of gestation as captured by The Joint Commission’s Elective Delivery (PC-01) measure to the Inpatient Quality Reporting Program (and Hospital Compare website) in 2013 for all patients (not just for births paid by Medicare). Reporting for all nulliparous, term, singleton, vertex cesarean sections would follow an established precedent.  With January 1, 2014, discharges, The Joint Commission began requiring the Perinatal Care Core Set (which includes PC-01 and PC-02) measures to be reported for accreditation of facilities with 1,100 or more births annually. With January 1, 2016, discharges, The Joint Commission began requiring Perinatal Care Core Set measures to be reported for facilities with 300 or more births per year. Elective Delivery (PC-01) and Cesarean Birth (PC-02) have been included, respectively, in the voluntary Adult Medicaid Core Set and the Children’s Health Insurance Program Core Set since 2011. In the voluntary Child Core Set, measurement of Cesarean Birth (PC-02) has thus far only risen from 2 states in FFY2010 to 16 states in FFY2014. Both of these measures have been endorsed by the National Quality Forum since 2008, Elective Delivery (PC-01)’s e-specification was also recently endorsed in 2016.                (Submitted by: The American College of Obstetricians and Gynecologists)

  • The Consumer-Purchaser Alliance is a collaboration of leading consumer, labor, and employer organizations committed to improving the quality and affordability of health care through the use of performance information to guide consumer choice, payment, and quality improvement. We appreciate the opportunity to provide comments on the MAP Hospital Workgroup Draft Report. Our comments below are numbered for clarity, not to indicate any prioritization of these issues. 1) We strongly support the emphasis on patient-reported outcome measures (PROMs) as a high priority target for measures to include in CMS’s programs. PROMs reflect issues that are important to patients and provide a valuable perspective that cannot be obtained from other data sources (e.g., severity of pain, physical functioning). They can complement, but not replace, clinical outcomes. When embedded in systematic care processes, PROMs open up new opportunities for patient engagement, care management, and performance improvement. 2) Members of the MAP Hospital Workgroup indicated support for continued development of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures measure. We feel this sentiment is not adequately captured in the final report. Shared decision making is a key component of patient-centered health care. It fosters clinician-patient partnerships in making decisions about tests, treatments, and care plans. Patients who are informed and effective managers of their own health are more likely to experience improved patient satisfaction, improved clinical outcomes, and lower health care costs. Unfortunately, informed consent is oftentimes a perfunctory process focused on ensuring legal aspects of care are addressed. These cases represent missed opportunities for meaningfully engaging patients in their health care decisions. Consumers and purchasers are very supportive of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures measure. By assessing the quality of informed consent documents, this measure goes beyond a check-the-box process measure. The measure also represents an innovative approach to using the informed consent process as a vehicle for shared decision-making. Lastly, we note that this measure serves to fill measure gaps identified in the report: cross-cutting measures, and, in particular, shared decision-making. 3) We greatly appreciate the Draft Report’s summary including reference to the hospital workgroup’s discussion on considering the amount of effort required for measure collection in the context of the information that will be obtained. Throughout the report, however, the report reverts back to looking at effort outside of this context and we believe this should be rectified to be consistent with the summary and workgroup discussion. Oftentimes the effort required of providers for measure collection is negatively characterized as a ‘burden’, particularly when the value of a measure is not taken into account. As we continue to strive for parsimonious, high-leverage measure sets, it is critical that the measurement effort on the part of the provider be weighed against the value of the information the measure furnishes. 4) We strongly support the American College of Obstetricians and Gynecologists’s (ACOG) request that MAP recommend adding a measure of low-risk cesarean section rate to the Inpatient Quality Reporting (IQR) Program. Measuring and tracking unnecessary cesarean sections is an important step towards improving perinatal care. As ACOG notes in their comments, The Joint Commission’s Cesarean Birth (PC-02) all-payer measure is ready to be implemented and would nicely complement the all-payer Elective Delivery measure now in use in IQR. PC-02 is NQF-endorsed and is a component of The Joint Commission’s Perinatal Care Core Set used for facility accreditation. As demonstrated during the Hospital Workgroup discussion in 2015, a perinatal measure is unlikely to be useful for a Medicare-only population (e.g., the VBAC measure considered and not recommended due to reliance on Medicare claims alone). However, an all-payer measure that captures rates of specific perinatal interventions and outcomes among all births would provide valuable information about hospitals’ maternity care quality. Our recommendation to add PC-02 to the IQR measure set would achieve that goal. We applaud ACOG for this leadership, and again note that because of the non-Medicare foundation for the proposed measure, we do not expect this measure to present itself on the Measures Under Consideration list without external prompting. Please note that ACOG’s request follows an established precedent. In 2013, hospitals began reporting a maternity measure, The Joint Commission’s Elective Delivery (PC-01), to the Inpatient Quality Reporting Program for all patients (not just for births paid by Medicare). (Submitted by: Consumer-Purchaser Alliance)

General
  • The National Association of Long Term Hospitals (NALTH) is pleased to submit comments on the following measures under consideration for use in the LTCH Quality Reporting Program (QRP): • Application of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened • Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings • Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings NALTH is the only hospital trade association in the nation that is devoted exclusively to the needs of patients who require services provided by LTCHs. NALTH is committed to research, education and public policy development that further the interests of the very ill and often debilitated patient populations who receive services in LTCHs throughout the nation. In December, the Measure Application Partnership (MAP) PAC/LTC Work Group made the preliminary recommendation to support the Application of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened measure for rulemaking and encouraged CMS to revise and resubmit the Transfer of Information measures. We have serious concerns regarding the pressure ulcer measure as described below. We agree with the MAP PAC/LTC Work Group’s recommendations with respect to the transfer of health information measures. We urge the MAP PAC/LTC Work Group to review these concerns before making final recommendations. Application of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened Inclusion of unstageable pressure ulcers in the numerator and the use of M0300 items instead of M0800 items to calculate the measure. NALTH supports the intent of the pressure ulcer measure, but believes that the modifications to the measure combined with the recommendation to use the M0300 items instead of the M0800 items to score the measure is problematic. Under CMS’s proposed measure specifications, the numerator would be modified to include unstageable pressure ulcers, including unstageable pressure ulcers due to slough or eschar, unstageable pressure ulcers due to non-removable dressing or device, and unstageable pressure ulcers presenting as deep tissue injuries. The modifications would unfairly penalize PAC providers as having a patient with a new or worsened pressure ulcer because the design of the M0300 items does not allow CMS to distinguish whether a pressure ulcer that becomes unstageable is truly a worsening of a pressure ulcer. For example, NALTH does not consider a stage 4 ulcer that becomes unstageable as a worsening of an ulcer because it is covered with slough or eschar. However, the measure specification indicates the numerator would flag a new or worsening pressure ulcer if the following occurs: • Stage 2 (M0300B1) - (M0300B2) > 0, OR • Stage 3 (M0300C1) - (M0300C2) > 0, OR • Stage 4 (M0300D1) - (M0300D2) > 0, OR • Unstageable – Non-removable dressing/device (M0300E1) - (M0300E2) > 0, OR • Unstageable – Slough and/or eschar (M0300F1) - (M0300F2) > 0, OR • Unstageable – Deep tissue (M0300G1) - (M0300G2) > 0 Thus, it would appear (assuming no other changes to any of the pressure ulcers and no new pressure ulcers) that in our example, the case would have Unstageable – Slough and/or eschar (M0300F1) - (M0300F2) > 0. Another example is when a patient comes into the PAC provider with an unstageable pressure ulcer and is revealed to be, for example, a stage 3 after debridement and other treatment. Without consideration of the M0800 items, this patient would again be flagged as having a worsened pressure ulcer because it has a Stage 3 (M0300C1) - (M0300C2) > 0. We strongly urge MAP to support the continued use of the M0800 items or recommend to CMS that other mechanisms should be developed to ensure that patients are not incorrectly flagged as having new or worsening pressure ulcers. Language modifications being explored with the term “pressure injury”. CMS is proposing to replace all instances of the term “pressure ulcer” with the term “pressure injury.” During the 2016 National Pressure Ulcer Advisory Panel Staging Consensus Conference, a pressure injury was defined as : Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This change in terminology creates a problem for medical coders as the current version of the ICD-10-CM does not include “pressure injury”. Instead, it has two terms used to describe pressure injury: decubitus ulcer and pressure ulcer. To avoid confusion until ICD-10-CM is appropriately modified, we urge MAP to recommend to CMS that the agency clarify through release of a public statement that all previous definitions in physician documentation indicating a pressure or decubitus ulcer should be considered a pressure injury and vice versa for coding purposes. Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings and Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings Additional clarifications in the measure specifications is needed for both measures. NALTH supports MAP’s recommendation for CMS to revise and resubmit the measures prior to rulemaking. We believe that transfer of health information and patient preference upon admission and discharge is important for improving transitions in care and ensuring the safety of patients, and share MAP’s concerns with the measures. NALTH recommends that MAP seeks additional clarification from CMS on the measure specifications. First, the measures are assessed at three time points: admission, start of care, and resumption of care. The measure specifications do not clarify when and how admission and start of care are different. In addition, the specifications should clarify if resumption of care refers to care beginning after a service interruption. NALTH believes that completing this information again after an interruption in service of less than 3 days is burdensome and not useful. Finally, LTCHs are allowed to conduct the admission assessments up to 3 days after admission. CMS should clarify if the measures would follow the same requirements. Thank you for providing us with the opportunity to comment on the 2016-2017 measures under consideration. If you have any questions about these comments, please contact Lane Koenig, PhD, NALTH Director of Research and Quality, at lane.koenig@knghealth.com. (Submitted by: National Association of Long Term Hospitals)

CAHPS Hospice Survey: Rating of Hospice (Program: Hospice Quality Reporting Program; MUC ID: MUC16-031)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. AAHPM appreciates the Hospital workgroup's thoughtful deliberations. AAHPM thanks the Hospital workgroup for the opportunity to review and comment on its draft report. We fully support the priorities identified in the subsection "Move to High-Value Measures" (p. 4), as these have implications for the care of seriously ill patients. In regards to the need for new and/or improved patient-reported outcome measures, it might be worth noting that any new measures should have some mechanism to account for instances in which patients' illnesses progress to a point where they are unable to advocate for themselves (eg, proxy reporting). Acknowledging the large number of competing priorities in new measure development, we also want to suggest a few other possible priority areas including care consistency with patient preferences for treatment, access to palliative care, and financial toxicity.  In the discussion of considerations for the (PPS)-Exempt Cancer Hospital Quality Reporting program (p. 6), we appreciate the workgroup's support of four measures related to end-of-life (EOL) care and its general acknowledgement of EOL in cancer care as an area of needed improvement. We want to note that although this discussion was in the context of the PCHQR, cancer is not the only disease that would benefit from improved attention in palliative care and EOL care.  Therefore, we ask that the Hospital workgroup consider encouraging measure developers in other diseases to work on developing these measures.   Finally, we appreciate the workgroup's thoughtful deliberation and recommendations on measures #056 and #167 (p. 8), as well as #263 (p. 10). Thank you again for your consideration of these comments and for all your work through the MAP cycle. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC appreciates the PAC-LTC workgroup’s thoughtful deliberations. CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • The National Coalition for Hospice and Palliative Care supports the use of this measure for the HQRP (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Hospice Team Communications (Program: Hospice Quality Reporting Program; MUC ID: MUC16-032)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • National Coalition for Hospice and Palliative Care recommends the use of this measure for HQRP (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Willingness to Recommend (Program: Hospice Quality Reporting Program; MUC ID: MUC16-033)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • We were surprised no revision to this measure was suggested. The denominator should be the total number of surveys, not the number of survey respondents answering the item. A non-response is a non-recommendation, and since the capacity of CAHPS questions to measure quality is restricted by ceiling effects, the correct definition would reduce the percentage of respondents at the top.  (Submitted by: American Institutes for Research)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • National Coalition for Hospice and Palliative Care recommends the use of this measure for the HQRP (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Getting Hospice Care Training (Program: Hospice Quality Reporting Program; MUC ID: MUC16-035)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Getting Timely Care (Program: Hospice Quality Reporting Program; MUC ID: MUC16-036)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Getting Emotional and Spiritual Support (Program: Hospice Quality Reporting Program; MUC ID: MUC16-037)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale because the measure has achieved NQF endorsement and has the potential to offer an indication of global quality of care. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Getting Help for Symptoms (Program: Hospice Quality Reporting Program; MUC ID: MUC16-039)
  • Adventist Health System supports this measure concept. We share MAP’s view that measuring patient and family caregiver perspective of how well providers address patients’ symptoms has the potential to offer an indication of global quality of care. However, we are concerned that this measure has not yet been submitted to NQF for endorsement review. We believe NQF endorsement is the best way to ensure that measures are indeed relevant to enhanced health outcomes and, particularly in this case, an indication of global quality of care. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For this reason, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the Hospice Quality Reporting Program. Therefore, we recommend that MAP withhold support for rulemaking for any measure until the measure achieves NQF endorsement. In addition to ensuring quality measures meet rigorous standards, we believe it is important for MAP to underscore to CMS the importance of NQF endorsement and the role NQF fills as a multi-stakeholder convener group. (Submitted by: Adventist Health System)

  • Adventist Health System supports this measure concept. We share MAP’s view that measuring patient and family caregiver perspective of how well providers address patients’ symptoms has the potential to offer an indication of global quality of care. However, we are concerned that this measure has not yet been submitted to NQF for endorsement review. We believe NQF endorsement is the best way to ensure that measures are indeed relevant to enhanced health outcomes and, particularly in this case, an indication of global quality of care. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For this reason, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the Hospice Quality Reporting Program. Therefore, we recommend that MAP withhold support for rulemaking for any measure until such measure achieves NQF endorsement. In addition to ensuring quality measures meet rigorous standards, we believe it is important for MAP to underscore to CMS the importance of NQF endorsement and the role NQF fills as a multi-stakeholder convener group. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

CAHPS Hospice Survey: Treating Family Member with Respect (Program: Hospice Quality Reporting Program; MUC ID: MUC16-040)
  • Adventist Health System supports this measure concept. We share MAP’s view that measuring family caregiver perspectives of how well providers treat patients with respect has the potential to offer an indication of global quality of care. However, we are concerned that this measure has not yet been submitted to NQF for endorsement review. We believe NQF endorsement is the best way to ensure that measures are indeed relevant to enhanced health outcomes and, particularly in this case, an indication of global quality of care. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For this reason, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the Hospice Quality Reporting Program. Therefore, we recommend that MAP withhold support for rulemaking for any measure until such measure achieves NQF endorsement. In addition to ensuring quality measures meet rigorous standards, we believe it is important for MAP to underscore to CMS the importance of NQF endorsement and the role NQF fills as a multi-stakeholder convener group. (Submitted by: Adventist Health System)

  • AAHPM recommends the use of this measure for the HQRP. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • CAPC thanks the PAC/LTC workgroup for the opportunity to review and comment on its draft report. In response to the workgroup’s discussion of the benefits and drawbacks of using the Patient-Reported Outcomes Measurement Information System (PROMIS) to shed light on work being done to increase the use of patient-reported outcomes (pp. 4-5), it is not clear in the report how the workgroup intends to use this information. That being said, we support the use of measures that have already been developed and tested rather than committing resources to new measure development, and look forward to more information from the workgroup. We fully support the priorities identified in the Hospice Quality Reporting Program (HQRP) that must be addressed in future rulemaking cycles (p. 9). Acknowledging the large number of competing priorities in new measure development, we also want to suggest financial toxicity as a possible priority measure. Additionally, we want to note that although this discussion was in the context of the HQRP, measure gaps in medication management, patient care preferences, symptom management in diseases besides cancer are relevant for other programs such as the Long-Term Care Hospital Quality Reporting Program (LTCH QRP), Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Home Health Quality Reporting Program (HH QRP). Thank you again for your consideration of these comments and for all your work throughout the MAP cycle. (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting (Program: ; MUC ID: MUC16-041)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need for the measure to be revised and resubmitted because it is currently undergoing field testing. AHS agrees with the Workgroup’s view that testing results should demonstrate reliability and validity at the facility level in the hospital setting. Furthermore, we support the Workgroup’s recommendation that the measure be submitted to NQF for review and endorsement. We believe NQF endorsement is the best way to ensure that measures are reliable and valid. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the IQR program or EHR Incentive program. (Submitted by: Adventist Health System)

  • While the AHA supports the recommendation to refine and resubmit this measure, there are remaining concerns that must be addressed. Several clinicians on the MAP noted occurrences where a patient with a condition not included in the denominator exclusions would be appropriately prescribed an antipsychotic medication. Because of this oversight, we hope that the measure developers will perform a more thorough analysis of the appropriate use of antipsychotics before resubmitting this measure. (Submitted by: The American Hospital Association)

Medication Continuation following Inpatient Psychiatric Discharge (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-048)
  • (Submitted by: Family Voices NJ)

  • This measure should more clearly define "evidence based medication." Information on how the measure was tested should be provided before adoption. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

  • We strongly support the recommendation that the measure be further tested and NQF endorsed before it is used in the payment system.  (Submitted by: National Association of Psychiatric Health Systems)

  • While not pulled for discussion, the AHA has technical and conceptual concerns about this measure as it is recommended to be refined and resubmitted. The largest technical concern is analysis of testing at the hospital setting, which is currently underway. The AHA also recommends that the refinement process clarify the definition of “dispensed” to reflect an item that can actually be gleaned from claims data. In many situations (such as VA or TriCare patients or for patients in an ACO), no claim is produced, so dispensing information would likely need to be available via another source. Conceptually, this measure is unlikely to provide valuable information about performance gaps due to its simplicity. The information the measure will produce will only echo information in discharge instructions and conditions of participation, not new or particularly insightful data. In addition, measuring whether a patient is “dispensed” medication in that he/she obtains it will likely result in broader Medicare policy issues. Specifically, prescription drug coverage is not required; thus, some (or many) patients may have financial challenges preventing them from actually obtaining the medication. IPFs that serve poorer patients will likely perform worse on this measure; such facilities that attempt to circumvent these financial challenges by buying prescriptions for their patients (for example) might risk infringing upon fraud and abuse laws. Without further clarification on the definition of “dispensed” and a concerted effort to tie this measure to processes and outcomes within the IPF’s control, this measure would be at best unhelpful. (Submitted by: The American Hospital Association)

Medication Reconciliation at Admission (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-049)
  • Need to consider lag time between E.R. and admission, particularly regarding destabilization of individuals with mental illness. (Submitted by: Family Voices NJ)

  • This measure should better define who is required to do the medication reconciliations. Could nurses perform the reconciliations? Could patients be involved in their own reconciliations? The numerator includes "indication." Are other departments or fields tracking indication in medication reconciliations? If so, what were the results? The measure does not clearly explain how the measure results are calculated. How are the three components averaged together? Consideration should be given to remove patients transferred from another IPF or acute care hospital from the exclusion criteria. Despite coming from another facility, medication reconciliations should still be performed to reduce medication discrepancies made during the transfer. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

  • We strongly support the recommendation that validity and reliability testing of this measure be completed and that it be NQF endorsed before it is used for payment and pubic reporting. We have concerns about several of the measure specifications. (Submitted by: National Association of Psychiatric Health Systems)

  • The AHA agrees that the measure needs further refinement, particularly in that it must be tested to ensure that it returns accurate, reliable results. It will also be important to carefully assess feasibility and burden of data collection, which can be difficult without EHRs. This is salient because freestanding IPFs do not participate in the Medicare EHR Incentive program, which means that some may not use EHRs. Or they may use EHRs whose standards for data sharing and transmissions are not the same as those of hospitals and physicians participating in the EHR incentive program. Moreover, most studies cited as the rationale behind this measure were not performed in the IPF setting. Further, the studies that were performed in the IPF study merely showed that many patients had medication errors in their history, not that IPFs were providing low-quality care regarding medication reconciliation. Conceptually, this measure is incomplete as it only measures “attempts” at medication reconciliation. Without clear standards as to the content of the med rec process, this measure is unlikely to provide any insight into the actual quality of care provided. (Submitted by: The American Hospital Association)

Tobacco Use Screening (TOB-1) (Program: ; MUC ID: MUC16-050)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need for the measure to be revised and resubmitted in order to better understand its overall impact on the quality of care. We support the Workgroup’s recommendation that the measure be submitted to NQF for review and endorsement. We believe NQF endorsement is the best way to ensure that measures are relevant to enhanced health outcomes. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the IQR program or EHR Incentive program. (Submitted by: Adventist Health System)

Influenza Immunization (IMM-2) (Program: ; MUC ID: MUC16-053)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. (Submitted by: Adventist Health System)

  • We understand MAP’s recommendation of conditional support for rulemaking of this measure. If the final decision is to move forward with this flu vaccine measure, we recommend NQF consider harmonizing the many flu vaccine measures with preference for a universal or “setting-independent” measure. Conversely, if the rates for the hybrid version of this measure are already high, we recommend retirement of the eMeasure. (Submitted by: America's Health Insurance Plans)

  • The AHA disagrees with the MAP’s recommendation to conditionally support this measure, and believes instead that it should not be supported. The only difference between this measure and the existing IMM-2 measure in the IQR is that this version is an e-measure; while members of the MAP concluded that the e-measure would be easier for providers to report, the AHA believes there remain many unanswered questions about the accuracy and feasibility of eCQMs. As a result, an overabundance of eCQMs may actually increase the reporting burden without providing data useful to providers and the public. In addition, it is unclear what performance gap this measure would close as the IMM-2 measure already shows little to no variation across providers. (Submitted by: The American Hospital Association)

Median Time from ED Arrival to ED Departure for Discharged ED Patients (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-055)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We are concerned about the Workgroup’s acknowledgement of the potential for unintended consequences and hope that this will be addressed and resolved via the NQF endorsement process. (Submitted by: Adventist Health System)

  • There needs to be data on mental health vs. physical health for parity. (Submitted by: Family Voices NJ)

  • Although this measure already exists in the Outpatient Quality Reporting program, making it an e-measure would not fix the inherent problems with it. While the existence of the measure in general was not up for a vote, the AHA would like to express concerns for its effectiveness. The time of arrival to the time of discharge in the ED does not necessarily provide insight into ED efficiency. In fact, longer time between arrival and discharge might be medically necessary and preferable to an inpatient admission; thus, requiring this measure might result in more unnecessary inpatient admissions as providers attempt to bring their reported times down. And, as always, it is important to consider how socio-demographic factors play into ED utilization. This measure does not include any provisions for adjustment based on socio-demographic factors, which would unfairly penalize providers who treat vulnerable populations. (Submitted by: The American Hospital Association)

Median Time to Pain Management for Long Bone Fracture (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-056)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the fact that NQF endorsement was removed in 2014. We believe NQF endorsement is the best way to ensure that measures are indeed evidence-based and relevant to enhanced health outcomes. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are reliable, valid, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the Hospital Outpatient Quality Reporting Program. (Submitted by: Adventist Health System)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • (Submitted by: Center to Advance Palliative Care)

  • We support for HOQR however we do not support for rulemaking. (Submitted by: National Coalition for Hospice and Palliative Care)

The Percent of Home Health Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Program: Home Health Quality Reporting Program; MUC ID: MUC16-061)
  • Adventist Health System (AHS) supports this measure concept. However, we believe that this particular measure should be resubmitted to NQF for endorsement to include the home health setting, in addition to the LTCH setting for which it received endorsement. It is our view that achieving NQF endorsement is the best way to ensure that measures are consistent across types of health care providers, including different post-acute care settings. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics. For this reason, we believe it is important that this measure be evaluated and endorsed for use specific to the home health setting prior to its implementation in federal programs, such as the Home Health Quality Reporting Program. We encourage MAP to recommend that CMS refine and resubmit this measure prior to rulemaking. Furthermore, we recommend that MAP withhold support for rulemaking for any measure until the measure achieves NQF endorsement specific to the facility it measures. In addition to ensuring quality measures meet rigorous standards, we believe this is the best way for MAP to underscore to CMS the importance of NQF endorsement and the role NQF fills as a multi-stakeholder convener group. (Submitted by: Adventist Health System)

  • Revision of the measure might also include specifying that the care plan and treatment plan be established *in collaboration with* the patient/resident and/or family. (Submitted by: American Institutes for Research)

  • We agree with MAP’s recommendation for conditional support to allow for additional testing at the home health setting. (Submitted by: America's Health Insurance Plans)

  • We concur with the statement that the variation in data collection makes communication about patient/resident functioning challenging when patients/residents transition from one type of provider to another. The collection of functional assessment data is feasible, but the additional specifications outlined in the measure, particularly in regards to duplicative types of transfers and other walking and activities of daily living functional assessments are extensive, time intensive, and require significant training. As a means to address the limited amount of time to address function, ARN recommends that function be assessed by the completion of standardized screening tools. A positive screening would then result in a more thorough, extensive, and specific assessment. (Submitted by: Association of Rehabilitation Nurses)

  • (Submitted by: Family Voices NJ)

  • In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the MAP Coordinating Committee reject the conditional support designation and instead consider the decision categories of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would like to note that while this measure has been implemented for other settings (IRF, SNF and LTCH), a Public Comment period concluded on December 9th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP. The proposed measure does not provide testing of this measure or the measurement items within the Home Health setting. While the items for this measure were a part of the PAC-PRD project, only 44 of the over 12,400 home health agencies participated in the project, representing less than 1% of all home health providers. Additionally, the PAC-PRD project collected admission and discharge assessments on roughly 4,500 home health patients, out of the nearly 3.4-3.5 million Medicare beneficiaries who utilize home health care services, again representing less than 1% of all home health episodes. Without proper testing of this measure within the Home Health setting, we question the reliability and validity of the data collection, and the resulting measurement values to be utilized for a quality reporting program. Additionally, the proposed measure and measurement items would also be placed on top of existing OASIS items which are found to be duplicative or similar in nature. Without testing the proposed items in conjunction with existing OASIS items, we cannot determine the reliability and validity of the information being collected and utilized as part of this measure. The proposed measure is also a process measure, requiring only that the provider assess, data enter, and transmit the data to CMS. A provider that may perform well on this measure does not necessarily mean that the provider is producing quality outcomes, but instead that they are able to assess and transmit data on patients. We question whether this process measure and the resulting measurement values are representative of the quality of care being delivered, and would ask CMS and the measure developers to provide evidence that this specific measure improves the quality of patient care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 13 items and another 2 pages to the existing 21 page SOC OASIS form, 22 page ROC OASIS form, and 15 page Discharge from Agency OASIS form. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP Coordinating Committee to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the MAP Coordinating Committee consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)

The Percent of Home Health Residents Experiencing One or More Falls with Major Injury (Program: Home Health Quality Reporting Program; MUC ID: MUC16-063)
  • Adventist Health System (AHS) supports this measure concept. However, we believe that this particular measure should be resubmitted to NQF for endorsement to include the home health setting, in addition to the LTCH setting for which it received endorsement. It is our view that achieving NQF endorsement is the best way to ensure that potential data collection challenges and risk adjustment factors unique to the home health setting are explored and resolved. In particular, patient self-reported data may present challenges related to subjectivity and actionability. Also, as MAP has suggested, there may be additional opportunities for home health providers to identify falls without patient report. These opportunities need to be vetted via the NQF endorsement process to ensure this measure is as objective and comparable across post-acute care settings as possible. AHS is also concerned that this measure has not been adequately assessed for risk adjustment, or stratification, to account for different patient populations. We believe that factors to be considered for risk adjustment should include the clinical factors identified by MAP (patient referral sources such as ambulatory, physician and alternate post-acute settings). Consideration should also be given to potential social risk factors, such as marital status (as a proxy for access to a family caregiver), housing stability and food insecurity. For these reasons, we believe it is important that this measure be evaluated and endorsed for use specific to the home health setting prior to its implementation in federal programs, such as the Home Health Quality Reporting Program. We encourage MAP to recommend that CMS refine and resubmit this measure prior to rulemaking. Furthermore, we recommend that MAP withhold support for rulemaking for any measure until the measure achieves NQF endorsement specific to the facility it measures. In addition to ensuring quality measures meet rigorous standards, we believe this is the best way for MAP to underscore to CMS the importance of NQF endorsement and the role NQF fills as a multi-stakeholder convener group. (Submitted by: Adventist Health System)

  • We agree with MAP’s recommendation for conditional support to allow for additional testing at the home health setting. (Submitted by: America's Health Insurance Plans)

  • Agree that this must also include home health settings but should include ALL falls, not just "major injury." (Submitted by: Family Voices NJ)

  • In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested. Accordingly, we suggest that the MAP Coordinating Committee reject the PAC/LTC Workgroup recommendation and instead consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". The proposed measure does not provide testing of the measure values or the measurement items within the Home Health setting, and the MUC List notes indicate that the measure is currently in the process of “Field Testing”. The referenced endorsed measure, NQF #0674, was tested on long-stay residents in a Skilled Nursing setting, where the resident had to be present for 101 days or more to be included in the measure. We would suggest that the skilled nursing setting differs greatly from home health services, and as such testing within the home health population should be required to determine the reliability and validity of the measurement items and resulting measurement values. We also question whether this measure adequately captures the quality of care provided by a home health agency, especially when a patient may experience a fall with major injury at a time when home health personnel are not present. Because this measure is not risk-adjusted and does not provide exclusion for circumstances that may occur when home health personnel are not present, a home health agency’s performance may be outside their control and instead be the result of negative patient actions. We would recommend CMS and their measure developer consider whether or not risk-adjustment factors and/or exclusion criteria could be added to account for circumstances that fall outside of the home health agency’s control. Based upon the information presented above, we again ask that the MAP Coordinating Committee consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)

Patient Panel Smoking Prevalence IQR (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-068)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. Moreover, we believe the Workgroup’s discussion highlights the importance of achieving NQF endorsement prior to implementation in federal programs. We believe NQF endorsement is the best way to ensure that measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, consistent across types of health care providers, and responsive to variations in patient characteristics, such as social risk factors, geographic region, attribution and other factors beyond hospitals’ control. For this reason, we recommend that MAP withhold support for rulemaking for any measure until the measure achieves NQF endorsement. (Submitted by: Adventist Health System)

Adult Local Current Smoking Prevalence (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-069)
  • (Submitted by: American Institutes for Research)

  • While the American Medical Association (AMA) does not disagree with the importance of tracking smoking prevalence, we do not believe that it is appropriate for this measure to be used in the MIPS. . Reporting the prevalence of tobacco use within a county at the physician or Accountable Care Organization (ACO) level does not provide meaningful and actionable information to physicians, other providers or patients within a community. Specifically, we do not believe that this measure is directly applicable and appropriately tested at either level. Perhaps more importantly, the measure developer has not adequately demonstrated how individual physicians or an ACO can influence a county smoking prevalence rate. The measure must address the community factors that can impact a patient’s ability to successfully quit smoking, including the availability of tobacco use cessation programs (CDC, 2014). Any new measures added to these programs should focus on areas that can help to drive improvement in the overall delivery of patient care, while also truly representing the quality of care provided by the measured entity. (Submitted by: American Medical Association)

Adult Local Current Smoking Prevalence (Program: Medicare Shared Savings Program; MUC ID: MUC16-069)
  • While the American Medical Association (AMA) does not disagree with the importance of tracking smoking prevalence, we do not believe that it is appropriate for this measure to be used in the MSSP program.Reporting the prevalence of tobacco use within a county at the physician or Accountable Care Organization (ACO) level does not provide meaningful and actionable information to physicians, other providers or patients within a community. Specifically, we do not believe that this measure is directly applicable and appropriately tested at either level. Perhaps more importantly, the measure developer has not adequately demonstrated how individual physicians or an ACO can influence a county smoking prevalence rate. The measure must address the community factors that can impact a patient’s ability to successfully quit smoking, including the availability of tobacco use cessation programs (CDC, 2014). Any new measures added to these programs should focus on areas that can help to drive improvement in the overall delivery of patient care, while also truly representing the quality of care provided by the measured entity. (Submitted by: American Medical Association)

HIV Medical Visit Frequency (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-073)
  • We support this measure for inclusion in federal programs as it is included within the HIV / HEP C Core Measures Collaborative Core Set. (Submitted by: America's Health Insurance Plans)

Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-074)
  • The MAP has recommended that this measure be refined and resubmitted after final review of testing results from the NQF Cardiovascular Standing Committee and addressing concerns raised regarding patients on the individual components of the combination pill. As you are probably aware, the measure is currently undergoing off-cycle review by the CV Standing Committee. The developer has submitted testing results, but has not addressed concerns regarding prescription of the individual components of the combination pill. The AHA will also be submitting the comments below to the CV Standing Committee for their consideration as they evaluate the measure for full endorsement. The AHA/ASA strongly supports the goal of having more self-identified black or African American heart failure patients treated with hydralazine/isosorbide dinitrate, however, we cannot support MUC16-74/NQF 2764 as currently specified. As we previously stated in our comments to NQF when the measure was undergoing review for trial use, we do not doubt that the developers share our goals of promoting evidence-based practice and addressing disparities in care. We are, however, very concerned that some aspects of the measure are inconsistent with the ACC/AHA clinical practice guidelines*. We also believe the measure is based on a somewhat questionable assumption that providers have taken a dismissive approach to the evidence for this combination therapy. It also fails to fully acknowledge the complexity of addressing race in medical practice and the potential adverse consequences of prescribing a costly, three-times-a-day medication with overt side effects. We have also reviewed the testing data provided by the developer as part of their application for full endorsement of the measure, as part of the current off-cycle review. The testing data not only provides ample evidence of the challenges of accurately collecting all the data required for the measure from electronic health records, but also, we believe, fails to demonstrate that the measure meets the minimum criteria for scientific acceptability required by NQF for full endorsement. In addition, the testing approach is based upon certain assumptions that we believe are faulty. Our specific concerns with the measure and the testing provided by the developer are further detailed below. In addition to the inconsistency with the guidelines noted above, the clinical trial evidence and guideline recommendations for this therapy were limited to patients with New York Heart Association (NYHA) functional Class III-IV, however, this criterion is not addressed in the measure. There is no exclusion for NYHA functional class I and II, for which there is not sufficient evidence of benefit. As such, it is likely that a large proportion of HF patients without current indications for hydralazine/isosorbide dinitrate combination therapy are included in the measure denominator. This may, in part, account for the remarkably poor performance rates on the measure in the developer’s testing. In section 1b.1 of their application for endorsement, the developers have stated that “there is no substitute for the fixed-dose combination therapy.” Among our most significant concerns about this measure is that the ACC/AHA heart failure guideline, which is cited as a source in the application, does not specify the fixed-dose combination, which is currently available only as a brand-name proprietary formulation (BiDil®), but the measure does. The requirement that only prescription of the fixed-dose combination can fulfill the measure is of concern for several reasons: 1) The observed differences in formulations (brand vs. generic), though valid, are theoretical and not proven to be of clinical consequence. 2) A number of the workgroup members involved in developing this measure have received consultant fees and/or honoraria from Arbor Pharmaceuticals, the company that produces Bidil®**. These relationships are not disclosed in the application for endorsement. We would strongly encourage NQF to consider requiring that disclosures of relevant relationships such as this as part of all applications for endorsement moving forward. 3) Insurance plans may be unlikely to pay for the more expensive fixed-dose combination unless the generic medications have been tried first. In addition, copays for the brand name formulation may be higher. This may result in unintended consequences, since patients may either not fill their prescriptions or physicians may avoid patients who can’t afford or won’t pay for the higher cost of the brand-name medication. 4) This requirement also means that physicians are unable to titrate the dose, which is especially critical for older patients, who may be unable to tolerate the fixed-dose combination. In addition, the measure, as currently constructed, does not allow providers to exclude patients from the measure for patient-specific reasons, such as refusal or intolerance, or for medical reasons other than the 5 specific contraindications identified in the measure. This seems contrary to the goal of more patient-centered, personalized care. We recognize the challenges of capturing unique, patient-centered reasons for failing to prescribe fixed-dose combination therapy in an EHR, however, this is critical, especially if the measure is attributed at the individual provider level. During the initial evaluation of the measure for approval for trial use, the Standing Committee and others expressed concerns regarding the restriction to only the brand name drug. This was also discussed by the MAP during their evaluation of the measure. Given this concern and the fact that the overall performance rates for the fixed dose combination were extremely low (ranged from 0-1.6%) in the three datasets used for testing, it would be very helpful to have an analysis of what the rates would be if prescription of the individual components of the combination therapy were included. It is also questionable whether these results demonstrate that the measure can identify meaningful differences in performance across measured entities. Finally, on p. 5 of the testing form the developer states: We would note that ejection fraction (EF) values from all three datasets were difficult to obtain given the ongoing challenges with collecting this data in discrete fields in EHRs. Because of this limited data, the testing provided in this document represents patients who are self-identified African American or black with a diagnosis of heart failure who were currently receiving ACE or ARB and beta-blocker therapy. Because a diagnosis of left ventricular systolic dysfunction (LVSD) or an EF <40% is a requirement for prescribing those two medications, if the EF or LVSD value was missing, we assumed that it was present if all of the other inclusion factors were met. We believe that this is a faulty assumption and that prescription of ACEI or ARB and beta-blocker is not a valid proxy for LVSD or an LVEF < 40%. This alone calls into question all of the testing results reported by the developer. For all of the reasons outlined above, the AHA strongly opposes endorsement of this flawed measure or its use in any accountability, payment or public reporting program as it is currently specified. (Submitted by: American Heart Association)

  • This measure is also confusing as written and defined. (Submitted by: American Institutes for Research)

  • The Association of Black Cardiologists (ABC) continues to express its strong support of quality measure (MUC16-74) — Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure (fixed dose) and advocate for its use in the Medicare program. We commend the National Qualify Forum (NQF) for its examination of how quality measurement can be used to address disparities in cardiovascular disease. The fixed dose measure, while a process measure, can be used as a proxy to achieve the outcome of reducing health disparities in the African American cardiovascular patient population. We recognize that the Measure Applications Partnership (MAP) Clinician Workgroup has recommended that measure MUC16-074 be resubmitted for consideration after review of testing results by the NQF Cardiovascular Standing Committee. While ABC supports a review of the testing results, the timing of the review disadvantages the most thorough vetting of the measure by the MAP Clinician Workgroup prior to finalizing its pre-rulemaking recommendations for measures to be included in Medicare’s quality programs for the 2018 performance year. Indeed, testing data showed that: - only 1.1 percent of all eligible patients are currently receiving the FDA-approved fixed dose combination therapy across 303 practices in the Southeast; - less than 1percent of eligible patients were prescribed the medication in the federally qualified and community health center sample; and - 0% of eligible patients were prescribed the medication in the integrated delivery system in the South that was measured.  The merit of this measure, and ABC’s support of it, is supported by results of the A-HeFT study, published in 2004 by the New England Journal of Medicine (NEJM) which examined whether a fixed dose of both isosorbide dinitrate and hydralazine provides additional benefit in blacks with advanced heart failure. This study demonstrated a significant 43 percent improvement in survival among black patients with advanced heart failure given isosorbide dinitrate plus hydralazine compared to a placebo group. Additionally, the rate of first hospitalizations for heart failure was reduced by 33 percent, as compared with that in the placebo group, and quality-of-life scores also improved compared to the placebo group. In fact, the A-HeFT trial was halted early due to a significantly higher mortality rate in the placebo group than in the group given the fixed-dose combination isosorbide dinitrate plus hydralazine. It should be noted that individual components of the combination therapy has been suggested to be adequately representative of the fixed-dose regimen. However, there is no FDA approved generic equivalent for the fixed-dose combination that led to the results of the A-HeFT. African Americans are at increased risk of heart failure and experience worse outcomes post-heart failure development. (1) Yet, studies show that African American with heart failure are not receiving guideline-recommended H-ISDN therapy when indicated. (2) There is a clear opportunity to close the disparity gap and improve outcomes for African American heart failure patients. While not a complete solution, this measure will at least drive better adherence to quality of care. We therefore strongly request NQF’s support for the measure. Founded in 1974, the Association of Black Cardiologists (ABC) is a nonprofit organization with an international membership 1,700 comprised of health professionals, lay members of the community (Community Health Advocates), corporate members, and institutional members. At the ABC, there is no issue more central to our cause than ensuring that all Americans are given the foremost care to combat, treat, and overcome cardiovascular disease. This includes the recognition that cardiovascular disease occurs disproportionately in African Americans. (1) Golwala H., Thadani U., Liang L. Use of Hydralazine-Isosorbide Dinitrate Combination in African American and Other Race/Ethnic Group Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction Journal of the American Heart Association. 2013;2:e000214; https://doi.org/10.1161/JAHA.113.000214 (2) ibid. ? (Submitted by: Association of Black Cardiologists)

  • The Healthcare Leadership Council (HLC) is writing to express its support for the National Minority Quality Forum's (NMQF) heart failure performance measure, MUC 16-74.    HLC, a coalition of chief executives from all executives within American healthcare, is the exclusive forum for the nation's healthcare leaders to jointly develop policies, plans, and programs to achieve their vision of a 21st century system that makes affordable, high-quality care accessible to all Americans.  Members of HLC - hospitals, academic health centers, health plans, pharmaceutical companies, medical device manufacturers, biotech firms, health product distributors, pharmacies, and information technology companies - envision a quality-driven system that fosters innovation.  HLC members advocate measures to increase the quality and efficiency of American healthcare by empahsizing wellness and prevention, care coordination, and the use of evicence-based medicine, while utilizing consumer choice and competition to elevate value.    HLC strongly believes that F-ISDN/HYN accomplishes these goals.  In African Americans with heart failure, this therapy is proven to reduce mortality by 43% and first-time hospitalizations for heart failure by 38%, while improving quality of life. However, only 7% of African Americans who are clinically eligible for the combination therapy are receiving it.  NMQF's quality measure would save lives by strongly encouraging healthcare providers to ensure that eligible African American patietns with heart disease receive the proper treatment.    Given the benefits of the treatment, HLC strongly urges the NQF not to require that the quality measure be refined and resubmitted.  This requirement would cause an additional delay in the review and approval of the measure.    Thank you for the opportunity to comment on this important issue.  HLC feels there is tremendous potential for the healthcare industry as a whole to encourage collaboration and quality improvement in order to achieve our shared goal of improving the value of healthcare delivery for all.  (Submitted by: Healthcare Leadership Council )

  • see comments on clinician workgroup recommendations/draft report. Draft Comment from Dr. Ofili for January 13 deadline. I am Elizabeth Ofili, MD, MPH, FACC.  I am the Morehouse School of Medicine Director and Senior Associate Dean of Clinical Research Center & Clinical and Translational Research.  I profoundly disagree with the MAP preliminary recommendation regarding MUC16-74, Fixed-Dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF)<40% on ACEI or ARB and Beta-blocker Therapy.  I strongly object to the MAP preliminary recommendation of "Refine and Resubmit Prior to Rulemaking" following "final review of testing results from the CV Standing Committee and addressing concerns raised regarding patients on the individual components of the combination pill".  I am requesting that the MAP Coordinating Committee change the preliminary recommendation to either "Support" or "Conditional Support" for the following reasons: 1.  I attended the December 12 meeting of the MAP Clinician Workgroup (CWG).  There was clearly confusion among the members regarding the science and evidence that were reviewed and approved during the 2015-2016 consensus standards approval process.  NQF staff failed to clearly communicate to the CWG that all evidence, including issues associated with use  the component compounds, was discussed extensively by the Cardiovascular Standing Committee, the Consensus Standards Approval Committee, and the NQF Executive Committee before each approved the eMeasure for the Trial Use.  The Same evidence was submitted to CMS through the JIRA system, as well as in response to two requests for additional information from CMS prior to the decision within CMS to include the measure on the December 1, 2016 MUC list. 2.  Prescribing of the component compounds separately as a substitute for the FDA-approved fixed-dose combination if off-label use and was determined to be inappropriate for inclusion in a performance measure.  The CWG appears to have been unaware of this face.  Off-label prescribing of the individual component compounds is neither evidence-based, nor the best clinical or economic interest of the patient. 3.  Every year thousands of heart failure patients are hospitalized or die due to failure to treat with the FDA-approved therapy.  Further delay in approving this measure cannot be enable because the group of cardiologists disagrees with the determination reached during the NQF consensus development process.  In closing, I would like the American College of Cardiology to collaborate with Morehouse School of Medicine, the National Minority Quality Forum, and the Association of Black Cardiologists in our collective effort to advance health equity and evidence based treatment of heart failure in African American patients. (Submitted by: Morehouse School of Medicine )

  • I am Richard Allen Williams, MD, President of the National Medical Association (NMA), and a founding member of the Association of Black Cardiologists. I am submitting this public comment to object to the preliminary MAP recommendation regarding MUC 16-74, Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-Identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy. I request that the MAP Coordinating Committee revise the preliminary recommendation to reflect "Support" or "Conditional Support". This revised recommendation would represent a consistent application of the MAP criteria and subcriteria across all measures under consideration, and the placement of priority on improvements in quality of care of measured by patient outcomes, and the reduction of inpatient and outpatient costs associated with failure to effectively and efficiently treat this patient cohort. These unnecessary costs are borne by payers as well as by patients through out-of-pocket co-pays and deductibles. The NMA represents the interests of more than 50,000 African American physicians and the patients they serve. Our support for MUC 16-74 is consistent with our role as the nation's leading force for parity and justice in medicine and the elimination of disparities in health care. Unfortunately, more than 10 years after FDA approved the fixed-dose combination of isosorbide dinitrate and hydralazine, only seven percent of eligible African American H patients are estimated to receive this life saving treatment, leading to thousands of deaths each year that could have been avoided. A clear indication of support for MUC 16-74 by the MAP Coordinating Committee will send a clarion call to providers, patients and policymakers alike that, when science and value are established and in sync, the National Quality Forum, the Centers for Medicare and Medicaid Services, and the nation's healthcare providers will take the lead in creating a health services delivery system that is responsive to the needs of all Americans. Thank you for your consideration. (Submitted by: National Medical Assocation)

  • While the National Minority Quality Forum cannot speak to all of the deliberations of the Clinician Workgroup (CWG), it did seem that for MUC16-74 the CWG became disoriented about what they were being asked to review and vote on, and NQF staff had some difficulty in getting them to confine their focus to the principal task of the CWG. More specifically, the discussion during the December 12 CWG meeting revealed both procedural and substantive weaknesses about the NQF MAP process. Based upon the questions asked and comments made by CWG members, there was a lack of clarity rgarding their role and value relative to the CMS MUC process, and concern about the lack of consistent guidance regarding input from other members of the public (including measure stewards). Further, since the CWG was not convened as scientific reviewers, they were insufficiently conversant with the science and evidence that undergird MUC16-74, with the measure specifications, or with the substance of the NQF deliberations that resulted in the eMeasure's approval for trial use. They did not have the most current and accurate information regarding the status of the measure testing associated with MUC16-74. Finally, while it may be constituted as intended, the composition of the CWG appeared to disadvantage the patient voice. The National Minority Quality Forum is concerned that these procedural and substantive challenges may have compromised the validity of the vote that was taken on December 12. The National Minority Quality Forum (NMQF) was pleased that the Centers for Medicare and Medicaid Services included MUC16-74 on the list that was sent to the National Quality Forum. Inclusion of MUC16-74 on the CMS MUC list was based upon their intra-agency assessment of the quality of the peer-reviewed evidence of clinical efficacy, the potential for this measure to improve the efficiency and precision of provider practice and beneficiary/patient outcomes, and to eliminate costs associated with avoidable inpatient and outpatient care. The National Minority Quality Forum does not concur with the preliminary MAP recommendation regarding MUC16-74. We request that the MAP Coordinating Committee revise the recommendation to "Support" or "Conditional Support". The information NMQF submitted to CMS, as well as our responses to two different requests for additional information during the CMS MUC internal review process, was the same information that was reviewed and adjudicated by NQF during their Consensus Development Process (CDP). The NQF CDP resulted in approval for trial use of the measure by their Cardiovascular Standing Committee, the Consensus Standards Approval Committee, and the Executive Committee of the NQF Board. It must be noted that the NQF application for approval as an eMeasure for trial use was the same application as that for measures requesting endorsement as a paper measure, including evidence, need, and feasibility. The criteria used to evaluate those components of the application were the same. Applications for eMeasures for trial use, by definition, will not have completed testing of validity and reliability; therefore, we were asked to submit our testing plan on the required testing attachment. The testing plan was included in the approval. It was concerning, therefore, that the discussion during the CWG meeting failed to assign priority to the findings of the NQF CDP or the CMS intra-agency clearance process. Performance and quality measures are designed to advance the provision of evidence-based clinical practice. They cannot assign equal or higher valence to professional opinion, or to off-label versus approved uses. They must always assign the highest value to the science. Economic considerations must factor in all costs, including those associated with hospitalizations and additional episodes of care, as well as the additional out-of-pocket costs for the patient associated with avertable inpatient and outpatient care. The MAP preliminary recommendation regarding MUC16-74 lacks scientific merit, is non-responsive to the charge to the CWG, and ventures into areas that have already been deliberated and resolved, including the inappropriateness of promoting off-label prescribing by physicians. MUC16-74 represents a true value proposition for CMS and its beneficiaries. We ask the MAP Coordinating Committee to take action that reflects these values. (Submitted by: National Minority Quality Forum)

  • My name is Beverly Oliver, MBA, MSN, FNP-BC, CHFN. I have a Chronic Care Clinic that sees Heart Failure patients. My readmission rate for my clinic's Heart Failure patients within 30 days is less than 2%. The success of my clinic comes from education, frequent office visits and IV Lasix prn. One of the major successes is also from titration and use of Heart Failure medicines. I have used Bidil for over five years and have seen a marked reduction in hospitalization, increase in EF and improvement in my patients' quality of life. I wish to express my objection to the MAP preliminary recommendation of “Refine and Resubmit Prior to Rulemaking” following “final review of testing results from the CV Standing Committee and addressing concerns raised regarding patients on the individual components of the combination pill.” I ask that the MAP Coordinating Committee change the preliminary recommendation to either “Support” or “Conditional Support.” From what I understand from colleagues who participated, there was a significant level of confusion during the discussion concerning the evidence that had already been approved during last year’s consensus standards approval process. NQF staff should have told the CWG that all scientific evidence regarding the measure, had been comprehensively considered by the Cardiovascular Standing Committee, the Consensus Standards Approval Committee, and the NQF Executive Committee before they each approved the eMeasure for Trial Use. Approval through the MUC MAP process represents a vital means of ensuring that this life-saving treatment reaches more patients. I urge you to fully support this measure and to recognize the growing importance of developing quality measures aimed at eradicating the health disparities we continue to face as a nation. (Submitted by: St Dominic Chronic Care Clinic)

HIV Viral Suppression (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-075)
  • We support this measure for inclusion in federal programs as it is included within the HIV / HEP C Core Measures Collaborative Core Set. (Submitted by: America's Health Insurance Plans)

Average change in back pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-087)
  • Overall, AAPM&R is in favor of this general measure and believe the three month follow up time is appropriate. (Submitted by: American Academy of Physical Medicine and Rehabilitation)

  • Measure specifications should also address adjustment for case mix, bias due to loss to follow-up, and some definition of clinically significant change (Submitted by: American Institutes for Research)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   In general, NASS found many of the measures very ambiguous. Further refinement is needed to better define measure goals and additional stratification or risk adjustment is needed to account for heterogeneity in patient populations. Although NASS does support quality improvement initiatives, we remind MAP about the significant administrative and cost burden that these measures impose on clinicians. NASS was disappointed to find out that the comments we submitted during the early comment period were not discussed during the December in-person meetings. During your second round of deliberations, NASS strongly urges MAP to consider the comments from those who will be directly impacted by these measures. Thank you for the opportunity to comment.   Specific Comments on Measures: MUC16- 87 – Average change in back pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure. - General Comments: o NASS does not believe measuring back pain following lumbar discectomy is appropriate.  Leg pain is a more appropriate metric for change following a discectomy rather than low back pain. Discectomy is mainly associated with leg pain, but fusion for conditions such as degenerative scoliosis, spondylolisthesis, etc. are often associated with both leg pain and low back pain.  Therefore, NASS does not support inclusion of this measure for inclusion in MIPS. o While assessing change in pain is a reasonable and standard approach, NASS asks how the data in this measure will be interpreted under MIPS?  Specifically, the change in pain is correlated to the baseline value – the worse the baseline pain, the larger the potential for change.  For example, a patient who has a baseline pain level of 8 can improve 8 points while a patient who has a baseline pain level of 4 can only improve for the maximum of 4 points.  According to how pain is assessed, the practices with more severe patients could fare better as there is a greater potential for change in pain.  If this measure is included in MIPS, NASS requests clarification as to how the data will be used to measure clinician performance? o While NASS appreciates the efforts to define spine issues, these measures are oversimplified.  We request that the measure be modified so it can more accurately differentiate surgeon goals, approaches, and patient metrics. - Measure Denominator:  The measure denominator includes patients age 18 years and older at the start of the procedure measurement period o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focused primarily on the Medicare population. - Measure Denominator Exclusions: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population. Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. Additionally, patients undergoing surgery due to tumor, trauma, infection, revision, or spinal cord compression should be excluded OR these patient populations need to be stratified to better account for the heterogeneity of these patients. - Timing of Measurement: o The measurement timeframe provides a window of 6 to 20 weeks to measure low back pain.  Literature demonstrates that pain improvement is not complete at 6 weeks.  Specifically, pain scores collected at 6 weeks are somewhat higher compared to pain scores collected at 12 weeks.  Furthermore, many patients typically use opiates immediately following operation, rendering early pain measurement less reliable.  Therefore, NASS recommends that the measurement timeframe be more narrow, particularly immediately following operation. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale.  The VAS and NRS are two different approaches in measuring pain.  Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done.  Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS.  Alternatively, the NRS could be used as the unit of measurement.  - Measure Implementation: o While we understand that this measure has been used in Minnesota public reporting, how would this measure be implemented on a large scale? Is this measure proprietary? How do users implement this measure into their EHR system and submit to CMS? (Submitted by: North American Spine Society)

Average change in back pain following lumbar fusion. (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-088)
  • Overall, AAPM&R is in favor of this general measure and believe the three month follow up time is appropriate. (Submitted by: American Academy of Physical Medicine and Rehabilitation)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16- 88 – Average change in back pain following lumbar fusion: The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion surgery. - General Comments: o While assessing change in pain is a reasonable and standard approach, NASS asks how the data in this measure will be interpreted under MIPS? Specifically, the change in pain is correlated to the baseline value – the worse the baseline pain, the larger the potential for change.  For example, a patient who has a baseline pain level of 8 can improve 8 points while a patient who has a baseline pain level of 4 can only improve for the maximum of 4 points.  According to how pain is assessed, the practices with more severe patients could fare better as there is a greater potential for change in pain.  If this measure is included in MIPS, NASS requests clarification as to how the data will be used to measure clinician performance? o While NASS appreciates the efforts to define spine issues, these measures are oversimplified.  We request that the measure be modified so it can more accurately differentiate surgeon goals, approaches, and patient metrics. - Measure Denominator:  The measure denominator includes patients age 18 years and older at the start of the procedure measurement period o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focused primarily on the Medicare population. o The inclusion criteria do not adequately stratify patients.  For example, a surgeon who predominantly performs fusions for deformity corrections has a very different patient population than one who performs degenerative fusions. NASS recommends that these patients are further stratified by fusion level. Generally, a 1-2 level fusion is used for degenerative cases, whereas deformity cases generally have greater than 3 levels of fusion or more. - Measure Denominator Exclusion: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population.  Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. Additionally, patients undergoing surgery due to tumor, trauma, infection, revision, or spinal cord compression should be excluded OR these patient populations need to be stratified to better account for the heterogeneity of these patients. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale.  The VAS and NRS are two different approaches in measuring pain.  Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done.  Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS.  Alternatively, the NRS could be used as the unit of measurement.  - Measure Implementation: o While we understand that this measure has been used in Minnesota public reporting, how would this measure be implemented on a large scale? Is this measure proprietary? How do users implement this measure into their EHR system and submit to CMS?   (Submitted by: North American Spine Society)

Average change in leg pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-089)
  • Overall, AAPM&R is in favor of this general measure and believe the three month follow up time is appropriate. (Submitted by: American Academy of Physical Medicine and Rehabilitation)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16- 89 – Average change in leg pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure - General Comments: o While assessing change in pain is a reasonable and standard approach, NASS asks how the data in this measure will be interpreted under MIPS? Specifically, the change in pain is correlated to the baseline value – the worse the baseline pain, the larger the potential for change.  For example, a patient who has a baseline pain level of 8 can improve 8 points while a patient who has a baseline pain level of 4 can only improve for the maximum of 4 points.  According to how pain is assessed, the practices with more severe patients could fare better as there is a greater potential for change in pain.  If this measure is included in MIPS, NASS requests clarification as to how the data will be used to measure clinician performance? o While NASS appreciates the efforts to define spine issues, these measures are oversimplified.  We request that the measure be modified so it can more accurately differentiate surgeon goals, approaches, and patient metrics. - Measure Denominator:  The measure denominator includes patients age 18 years and older at the start of the procedure measurement period. o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focused primarily on the Medicare population. - Measure Denominator Exclusions: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population.  Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. Additionally, patients undergoing surgery due to tumor, trauma, infection, revision, or spinal cord compression should be excluded OR these patient populations need to be stratified to better account for the heterogeneity of these patients. - Timing of Measurement: o NASS notes that many patients typically use opiates immediately following operation, rendering early pain measurement less reliable.  Therefore, NASS recommends that the measurement timeframe be more narrow, particularly immediately following operation. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale.  The VAS and NRS are two different approaches in measuring pain.  Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done.  Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS.  Alternatively, the NRS could be used as the unit of measurement.  - Measure Implementation: o While we understand that this measure has been used in Minnesota public reporting, how would this measure be implemented on a large scale? Is this measure proprietary? How do users implement this measure into their EHR system and submit to CMS? (Submitted by: North American Spine Society)

Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-142)
  • Adventist Health System (AHS) recommends that short stay residents be excluded from this measure if the initial and subsequent assessments indicate DTPI is present and worsens. Our rationale is that DTPI may present initially as a discoloration or bruised/injured area and through normal proliferation of the wound, open to depths of stage 2 or greater depending on the extent of injury. (Submitted by: Adventist Health System)

  • In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup recommendation does not meet the conditions required for a “Support’” designation, and the MAP Coordinating Committee instead consider the decision categories of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the SNF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 2% for SNFs, as detailed in the most recently published CMS SNF Compare statistics for national average values. While the measure may be able to differentiate value amongst some of the SNFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of SNF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the MAP Coordinating Committee consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the MAP Coordinating Committee consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)

Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-143)
  • Adventist Health System (AHS) supports MAP’s preliminary decision. We appreciate MAP’s concerns about what it views as material revisions to the measure for the IRF but want to emphasize the importance of reaching a conclusion promptly. There is a need for a consistent measure that produces results that are comparable year over year. Otherwise, it will be difficult for providers to identify and address performance trends. That said, if MAP feels strongly that the recent revisions could lead to inconsistencies that may materially affect the public reputation of providers were this measure to be implemented in the IRF Quality Reporting Program, then MAP should recommend that this measure be refined and resubmitted. It may also be necessary for the measure to complete a new NQF endorsement review to ensure that it is reliable. However, AHS does not believe the revisions rise to this level of significance. (Submitted by: Adventist Health System)

  • AMRPA agrees with the MAP’s conditional support of this measure for rulemaking. We share the Workgroup's concerns regarding the impact of the material revisions to the measure for the IRF setting. We have discussed similar issues in our comments submitted in response to NQF’s Measures Under Consideration (MUC) list in December 2016. AMRPA’s members have raised concerns that the proposed measure’s changes for IRFs (i.e. replacing IRF-PAI items M0800 A-F with a calculation derived from item M0300) would overestimate the number of new/worsened pressure ulcers, and subsequently the number of patients with new/worsened pressure ulcers. Hence, AMRPA supports the MAP’s recommendation that CMS examine the measure and its impact more closely and not implement the measure for IRFs until the data can be considered consistent and reliable. (Submitted by: American Medical Rehabilitation Provider Rehabilitation Association)

  • HealthSouth does not believe this measure should be supported for endorsement until further analysis can be conducted on the effect of the changes proposed.  We support CMS’ intention to facilitate cross-setting quality comparisons; however, we are cautious of replacing a question that directly collects the information with a calculated or derived measure.  Following the announcement of the proposed change, we conducted a review of pressure ulcer data and modeled the changes that would occur under the newly proposed items.  The resulting data show a significant overestimation in the number of new/worsened pressure ulcers, at the item level, as a result of calculating the measure from the proposed item M0300 responses compared to the current measure, which utilizes direct responses from item M0800 (excluding the increase from the additional “unstageable pressure ulcers”).  The data we reviewed, pulled from over 86,000 IRF PAI records submitted to CMS after October 1, 2016, shows that .99% of patients with new or worsened pressure ulcers (including unstageables) using the existing measure calculation from item M0800, while 1.48% of patients with new or worsened pressure ulcers (including unstageables) using the newly proposed calculation from item M0300.  Based on this leap in patients with pressure ulcers resulted from the utilization of the newly proposed item, MUC16-143 would very likely cause a significant change to the calculation of the measure, and thus should not be adopted until the variance can be accounted for.  We would encourage CMS to collect the information directly, in all settings, instead of deriving/calculating the measure. Furthermore, during the MAP PAC/LTC workgroup meeting, CMS contractors confirmed that the proposed changes to the measure items and calculations are based on contractor research that is not publicly available.  It is troubling that proposals which significantly alter measures are premised on non-public information.  Transparency is a core principle of the National Quality Forum (“NQF”).  Without any supporting evidence as to why the change is reasonable or necessary, CMS has offered no rationale as to why the newly proposed items and calculations are an improvement over the existing ones. We do support CMS’ proposal to align the pressure injury terminology with the National Pressure Ulcer Advisory Panel, although during the MAP discussion some stakeholders made it clear that this decision was controversial within NPUAP.  Due to technical difficulties, public comments were not taken by phone regarding the IRF QRP measures.  There was no consideration to open public comment at a later time once the technical difficulties were resolved. (Submitted by: HealthSouth)

  • In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup recommendation does not meet the conditions required for a “Conditional Support’” designation, and the MAP Coordinating Committee instead consider the decision categories of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the IRF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. A review of the UDSMR IRF database indicates that a change to the new items would increase the number of cases identified as having a new or worsened pressure ulcer by 60%, bringing into question the reliability and validity of the item set utilized for this purpose. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 1% for IRFs, as detailed in the most recently published CMS IRF Provider Preview Reporting. While the measure may be able to differentiate value amongst some of the IRFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of IRF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the MAP Coordinating Committee consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the MAP Coordinating Committee consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)

  • To: The National Quality Forum (NQF) From: The Centers for Medicare & Medicaid Services (CMS) and RTI International Date: December 22, 2016 Subject: Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (NQF #0678): Response to NQF Steering Committee Concerns Regarding Inpatient Rehabilitation Facility Measure Background and Context On December 14, 2016, the Measure Application Partnership Post-Acute Care/Long Term Care Workgroup (MAP PAC/LTC or MAP) met, discussed, and voted on the measure under consideration (MUC16-143) Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (NQF #0678) for Inpatient Rehabilitation Facilities (IRFs). This measure reports the percentage of IRF patient stays with Stage 2-4 or unstageable pressure ulcers that are new or worsened since admission. This measure is a modification of the measure Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (NQF #0678). CMS submitted the measure to the Measures Under Consideration (MUC) List, along with analogous measures for Long Term Care Hospitals (LTCHs) (MUC16 – 144), Skilled Nursing Facilities (SNF) (MUC16 – 142) and Home Health Agencies (HHAs) (MUC16 – 145), as they were seeking to make the following substantive changes to the measure: 1. The addition of unstageable pressure ulcers due to slough or eschar, unstageable pressure ulcers due to non-removable dressing or device, and unstageable pressure ulcers presenting as deep tissue injuries in the numerator, as recommended by a cross-setting pressure ulcer Technical Expert Panel (TEP) and supported by the National Pressure Ulcer Advisory Panel (NPUAP), and 2. The use of M0300 (M1311 OASIS) items instead of M0800 (M1313 OASIS) items to calculate the quality measure. This modification is intended to: a. Facilitate cross-setting quality comparison as specified by the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act), b. Allow alignment between payment and quality measures, c. Reduce redundancies in assessment items, and d. Counterbalance the possible incentives to over- or underreport pressure ulcers that exist in the SNF setting. e. Prevent inappropriate underestimation of pressure ulcers through the use of the M0800 items. While the MAP provided a vote of “support” for the quality measures in the LTCH, SNF and HHA settings, questions were raised by members of the MAP and public commenters (Uniform Data System for Medical Rehabilitation (UDSMR)) regarding the reliability of the measure in the IRF setting. One provider-organization member of the MAP (HealthSouth) and same members of the public were specifically concerned with substitution of a calculation using M0300 data items in place of the current method of using M0800 data items to calculate the quality measure. The provider referenced analyses they had conducted on data obtained during the month of October 2016 in which their calculation of new or worsened pressure ulcers using M0300 data items did not correspond with results using M0800 data items. As a result, the IRF measure received a vote for “conditional support” contingent upon CMS and the measure developer providing additional information regarding the measure reliability and addressing data concerns brought up by the IRF provider. We have drafted this memo in order to meet contingencies imposed by the MAP and to address specific concerns identified by the MAP committee. We have summarized the MAP’s major concerns regarding the measure, as well as our response to each concern below: Concern 1: Data element reliability and validity. MAP Workgroup Members questioned whether data element reliability and validity were sufficiently demonstrated for the IRF setting, and if the data were publicly available. Summary response: Data element reliability and validity for the M0800 and M0300 pressure ulcer items has been tested in several ways. Rigorous testing on the reliability and validity of the nursing home (NH) items in the MDS 3.0 provides evidence for the items used in the IRF setting, as well as LTCH and SNF settings. We also cite strong reliability results for items equivalent to M0300 counts and assessment items tested in all three PAC setting. Below, we provide evidence of publicly available testing results on the validity and reliability of the data elements. Concern 2: Measure score reliability for IRF settings and reconciliation of data presented to the MAP. The MAP expressed concern regarding different findings on the impact of the use of M0300 items instead of M0800 items to calculate the pressure ulcer quality measure score in the IRF setting. While the measure developer, RTI, reported a decrease in the IRF pressure ulcer measure score using the M0300 item calculation with 2014-2015 data, an IRF provider, HealthSouth, reported an increase in the count of pressure ulcers using the M0300 item calculation versus the M0800 items using Q4 CY16 data. The MAP requested reconciliation of the data. Summary response: We provide additional information regarding RTI’s analyses of the impact of transition to the use of the M0300 Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) items to calculate the quality measure. We also provide potential reasons for variances between RTI testing and the results presented by HealthSouth. These potential reasons include differing calculation methods (counts vs. measure scores), time periods (2016 data vs. 2014-2015 data), length of time analyzed (one month vs. six months) and potentially differing treatment of missing data. While our recent analyses provide similar results to those presented to the MAP on December 14th, we conducted additional analyses to show why the M0300 calculation method is superior to the M0800 method of calculating the measure and is more accurate. The M0800 method is systematically undercounting new or worsened pressure ulcers in the IRF setting. We also provide results showing this finding is consistent with suspected undercounting of pressure ulcers in LTCH and SNF settings. Finally, we provide the results of a more recent (October 2016) analysis of IRF-PAI data, conducted by RTI, to explore potential variances between calculation of the quality measure using M0300 items and M0800 items. To briefly summarize our findings, this memo provides the reader with detailed information that addresses the MAP’s concerns showing the strength of our inter-rater agreement analyses for the MDS 3.0 and additional setting specific inter-rater reliability testing of pressure ulcer items similar to those used to calculate the quality measure in the IRF, LTCH and SNF settings. We provide further evidence that this testing information is publicly available through published studies and reports. With respect to the MAP’s concern regarding reliability of the quality measure calculation using M0300 items, we offer solid evidence to show why the M0300 calculation method is more accurate compared to the M0800 method of calculation, as well as an accounting of the potential reasons for variances between our testing and the results presented by HealthSouth. Full memorandum linked here: CMS Memorandum (Submitted by: Centers for Medicare & Medicaid Services)

Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-144)
  • Adventist Health System supports MAP’s preliminary decision and rationale. (Submitted by: Adventist Health System)

  • In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup recommendation does not meet the conditions required for a “Support’” designation, and the MAP Coordinating Committee instead consider the decision categories of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the LTCH QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 2% for LTCHs, as detailed in the most recently published CMS LTCH Compare statistics for national average values. While the measure may be able to differentiate value amongst some of the LTCHs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of LTCH performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the MAP Coordinating Committee consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the MAP Coordinating Committee consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)

The Percent of Residents or Home Health Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Program: Home Health Quality Reporting Program; MUC ID: MUC16-145)
  • Adventist Health System strongly supports MAP’s preliminary decision and rationale. (Submitted by: Adventist Health System)

Febrile Neutropenia Risk Assessment Prior to Chemotherapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-151)
  • Amgen does not agree with MAP’s recommendation of “conditional support” of MUC16-151 for inclusion in the Merit-based Incentive Payment System (MIPS) Program. Instead, we recommend that this measure receive full support. Amgen supports the ongoing efforts of the National Quality Forum (NQF) Measure Application Partnership (MAP) to address priority measure gaps that have previously been identified by the MAP. The NQF MAP identified complications [such as febrile neutropenia(FN)] as a measure gap for cancer in the NQF MAP June 2012 report for a Performance Measurement Coordination Strategy for PPS-Exempt Cancer Hospitals and restated this gap in Appendix E to the January 2013 Pre-Rulemaking Report. FN is a true medical emergency, as both FN and severe neutropenia can lead to dose-delays, dose-reductions, and/or chemotherapy discontinuations, interfering with the delivery of optimal treatment and possibly leading to death or adversely affecting patient outcomes (Lyman 2010, Kuderer 2006, Smith 2006, Bonadonna 2005, Lyman 2003, Kwak 1990). The NQF-endorsed FN risk assessment measure addresses this significant gap by evaluating whether or not a risk assessment was done and documented prior to the first cycle of intravenous chemotherapy in those patients with a solid malignant tumor or lymphoma. Regarding the MAP’s issue with the cases in which institutions have specific risk assessment protocols, we recommend that, for purposes of reporting on MUC16-151, institutions must use protocols that adhere to current nationally recognized guidelines. Additionally, we recommend that there be clarification for clinics that use risk assessment protocols which incorporate patient-level factors. Because the presence of risk factors may significantly impact the risk for FN, these patient-level protocols must be able to accurately capture the risk of FN for each patient; otherwise a patient level assessment would still have to be done. In conclusion, the FN risk assessment measure addresses a well-recognized measure gap and should receive full support from MAP, which will help improve the clinical care of cancer patients. (Submitted by: Amgen)

  • As the developer of this measure we would like to offer the requested clarification how risk assessment for febrile neutropenia (FN) should be handled in a protocol-based system. Our short answer is that a protocol-based risk assessment meets the criteria set forth by the measure IF it gives appropriate consideration to both patient-level and regimen-level risk factors. Our rationale is the following: Current guidelines recommend CSF prophylaxis if the expected FN risk is greater than 20%. This risk, however, depends on the inherent myelotoxicity of the chemotherapy regimen and various patient factors, like age, prior treatment and comorbidities. There are regimens with an inherent toxicity that will always result in a risk of greater 20%, but there are also regimens, for which the FN risk will be above 20% only in patients with risk factors like age and comorbid conditions. Thus, a protocol-based system ought to incorporate both determinants of FN risk. We would also like to clarify that the measure intends to capture and encourage appropriate use. As the Workgroup correctly pointed out, the measure will make it more likely that patients with high FN risk receive beneficial CSF prophylaxis. But it will also make it less likely that low-risk patients receive an expensive treatment with possible side effects. For those reasons, we would argue that the measure should receive full rather than conditional support. (Submitted by: RAND Health)

Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-152)
  • This measure is still in development, and its inclusion on the MUC List was premature. Testing to support its specifications and risk adjustment models has just been completed, but the results have not been made available to the project TEP or to the public. The developers should assess the measure results to ensure that the measure does not inappropriately penalize centers with a more complex case mix. We support the preliminary “Refine and Resubmit” recommendation. (Submitted by: ASC Quality Collaboration)

  • Not only is this measure appropriate and meaningful, but it also addresses a gap in measurement in ASCs. Future studies are needed to support the seven-day cutoff period. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16-152- Hospital Visits following Orthopedic Ambulatory Surgical Center Procedures: The measure score is an ASC-level rate of unplanned hospital visits within 7 days of an orthopedic procedure performed at an ASC.  - General Comments: o NASS agrees with MAP’s preliminary recommendation that further refinement of the measure is needed. - Measure Denominator: The measure denominator includes Medicare FFS patients aged 65 years and older undergoing orthopedic surgeries performed at ASCs. o NASS is concerned that this this measure is solely specialty focused, rather than disease/condition focused. The type of orthopedic surgery performed at ASCs varies greatly, including procedures such as lumbar discectomy, minimally invasive spine surgery, and surgeries of the hand, foot and ankle. How will CMS account for these variations? - Risk Adjustment: o Other than 090 versus 010, will this be risk adjusted for comorbidities?  - Unintended Consequences: o NASS cautions about the unintended consequences of these types of outcome measures. Public reporting can create a competitive atmosphere, increasing the perceived need to only report good outcomes. Will this incentivize more procedures to be done in hospitals, at a higher cost to CMS?  (Submitted by: North American Spine Society)

Hospital Visits after Urology Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-153)
  • This measure is also still in development, and its inclusion on the MUC List was premature. Testing to support its specifications and risk adjustment models has just been completed, but the results have not been made available to the project TEP or to the public. As with the related orthopedic measure, we believe the developers should assess the measure results to ensure that the measure does not inappropriately penalize centers with a more complex case mix. We support the preliminary “Refine and Resubmit” recommendation. (Submitted by: ASC Quality Collaboration)

  • Not only is this measure appropriate and meaningful, but it also addresses a gap in measurement in ASCs. Future studies are needed to support the seven-day cutoff period. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC16-155)
  • The ASC Quality Collaboration supports this measure, which focuses on a significant surgical outcome and could fill an identified gap in the ASCQR Program. The measure is fully developed and tested and is already in use by ASCs in selected States for public reporting. The measure is being considered by the NQF for endorsement. Although MAP Measure Selection Criterion #1 states, “NQF-endorsed measures are required for program measure sets, unless no relevant endorsed measures are available to achieve a critical program objective,” we believe NQF endorsement is, in fact, not required. We base this on a direct reading of the Social Security Act, with corroboration from CMS, which has repeatedly stated NQF endorsement of measures is not required. In a recent example (see 81 FR 79808, November 14, 2016), CMS stated “…section 1833(t)(17)(C)(i) of the Act does not [emphasis added] require that each measure CMS adopts for the ASCQR Program be endorsed by a national consensus building entity, or the NQF specifically. Further, under section 1833(i)(7)(B) of the Act, section 1833(t)(17)(C)(i) of the Act applies to the ASCQR Program, except as the Secretary may otherwise provide. Under this provision, the Secretary has further authority to adopt non-endorsed measures. While we strive to adopt NQF-endorsed measures when possible, we believe the requirement that measures reflect consensus among affected parties can be achieved in other ways, including through the measure development process, through broad acceptance and use of the measure, and through public comments.” MAP should revise Measure Selection Criterion #1 to reflect the fact that NQF endorsement of measures is not required. (Submitted by: ASC Quality Collaboration)

  • The measure should include hospital outpatient departments due to the overlap of procedures performed at outpatient departments and ASCs, alike. There is serious concern about the feasibility to collect this data, given the current lack of data infrastructure. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

  • The AHA agrees with the MAP’s preliminary decision to support the inclusion of this measure on the condition of NQF endorsement and additional testing for implementation in the ASCQR program, and specifically asks for additional clarification on the data collection requirements. Clinical subject matter experts on the panel stated that there are differential rates of infection between major procedures like mastectomy and common, minor procedures like biopsies; thus, requiring the calculation of the standardized infection ratio (SIR) for all procedures would likely result in low numbers and not much variation among sites. It was unclear from the discussion and measure specifications whether the measure would be based on discrete CPT codes to differentiate breast procedures, which would be helpful to capture the clinical discrepancies. (Submitted by: The American Hospital Association)

Follow-Up After Hospitalization for Mental Illness (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-165)
  • Adventist Health System believes this is an important measure concept. We agree with the Workgroup that this particular measure should be refined and resubmitted to NQF for endorsement to include the hospital facility. It is our view that achieving NQF endorsement is the best way to ensure that measures are relevant and actionable at the setting they measure. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, feasible to collect and report, and responsive to variations in patient characteristics. For this reason, we believe it is important that this measure be evaluated and endorsed for use specific to the hospital setting prior to its implementation in federal programs, such as the Hospital Inpatient Quality Reporting Program. (Submitted by: Adventist Health System)

  • Agree with facility level for quality improvement. Still need to look at age due to shortage of pediatric mental health providers. (Submitted by: Family Voices NJ)

  • The AHA disagrees with the MAP’s recommendation to refine and resubmit this measure, as any degree of revision would still leave this measure unable to truly attribute quality of care to a hospital provider. The most pressing concern regarding this measure is technical: it is designed and tested as a health plan measure rather than at the facility level. In addition, it was tested on all-payer data, not the Medicare data that would, presumably, be used to calculate the measure in the IQR. Furthermore, we seriously question the appropriateness of attributing the completion of a follow up appointment to a hospital, rather than a health plan or integrated delivery network. By using this measure, CMS is effectively assuming that individual hospitals have the power to compel a patient to access the next level of care. A health plan, which by definition is measuring covered lives, can more easily ensure that a patient can pay for a follow-up appointment; an integrated delivery network can more easily make referrals to and share information with follow-up care providers. Individual hospitals, especially but not limited to rural and underserved urban providers, struggle immensely with identifying available behavioral health care providers for follow up care, let alone ensuring that patients actually go to a follow up appointment. There is no question that, at the time of discharge, providers need to help identify the next appropriate level of care; in fact, providers can even make appointments on behalf of the patient. However, due to many circumstances outside of the provider’s control (e.g. distance to follow-up care provider, cost of care, ability to communicate remotely with patient), it is unreasonable to expect all providers to ensure the completion of follow-up care. (Submitted by: The American Hospital Association)

Safe Use of Opioids – Concurrent Prescribing (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-167)
  • AAHPM does not recommend the use of this measure. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • The NQF MAP recommended “do not support for rulemaking” MUC 16-167 Safe Use of Opioids – Concurrent Prescribing. The ACS disagrees with the MAPs recommends and supports “Refine and Resubmit Prior to Rulemaking,” with conditions submitted below. Beginning in the late 1990s, patient advocacy organizations began asking the medical community whether pain was being under-treated. In 1999, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, urging doctors to assess pain at every visit. Other major health care accreditation and regulatory authorities followed suit, including the Joint Commission. As a result, pain scores are now used as a quality measure, including in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. This has led to an increase in opioid medication prescribing when acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) fail. More than two decades later, physicians are still expected to treat this highly subjective “5th vital sign,” as patients often have the unreasonable expectation that they are to be pain free. The requirement to treat pain, along with a number of other factors, has led to a major increase in overuse, misuse, abuse, and diversion of these highly addictive medications. The ACS commends CMS on their current efforts to address the overuse of opioids with proposing MUC 16-167 for consideration in the Hospital Inpatient Quality Reporting Program and the Hospital Outpatient Quality Reporting Program. The Centers for Medicare & Medicaid Services (CMS) measure titled Safe Use of Opioids – Concurrent Prescribing (MUC 16-167) measures the proportion of patients ages 18 years and older with active, concurrent prescriptions for opioids or with active, concurrent prescriptions for an opioid and benzodiazepine at discharge. The intent of the measure is to reduce risk of respiratory depression, preventable mortality, and lower costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more different opioids or opioids and benzodiazepines concurrently. ACS asserts that the opioid public health problem must be a multifaceted approach involving all stakeholders, including policymakers on both the national and state level. We believe that the alignment of state mandates and federal guidelines on prescribing limits are critical. We think this alignment will help to address the opioid epidemic by making prescribing information available to all of a patient’s providers. We also strongly support efforts which will require states to have functioning Prescription Drug Monitoring Programs (PDMPs) that are interoperable with Electronic Health Records (EHRs); however, physicians’ utilization of PDMPs should remain voluntary. We support PDMP access for physicians, licenses independent practitioners (LIPs), physicians’ designated agents, and pharmacists. Additionally, we support the ability to e-prescribe and think it would be beneficial in cases of prescribing limits under 30 days in helping to reduce fraud. As stated, the NQF MAP reviewed this measure and recommended “Do Not Support for Rulemaking.” The NQF MAP did not support this measure because it believes there are many conditions where concurrent prescriptions are appropriate and expressed concern that patients may unintentionally suffer withdrawal symptoms if their prescriptions are reduced and/or stopped. Additionally, the NQF MAP noted that 2016 CDC Guideline for Prescribing Opioids for Chronic Pain are not evidence-based. The ACS disagrees with the NQF MAP’s recommendations and believes with further refinement this measure would be appropriate for rulemaking, pending NQF endorsement. We have reviewed the measure and recommend the inclusion of two additional measure exclusions/exceptions: • Exclusion for patients who are undergoing withdrawal therapy: To address one of the concerns of the NQF MAP-that patients may unintentionally suffer withdrawal symptoms if previously prescribed opioids and/or benzodiazepines are reduced and/or stopped prior to discharge-the ACS recommends an exclusion for patients who are undergoing withdrawal therapy. • Exception for postoperative and/or injured surgical patients when clinically appropriate: The CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 states that the use of opioids should be limited to =3–7 days. However, there are circumstances where more than 7 days of postoperative pain relief necessitating opioids is appropriate. In these circumstances, ACS supports an exception for postoperative and/or injured surgical patients beyond 7 days and up to a reasonable limit, based on the professional opinion of the attending physician. The ACS supports the existing exclusion from prescriber mandates included in this measure for patients undergoing cancer treatment and/or palliative care. “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016” n.d. Web. 13 Jan. 2017. Available at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. (Submitted by: American College of Surgeons)

  • (Submitted by: Center to Advance Palliative Care)

  • The National Coalition for Hospice and Palliative Care does not recommend this measure for inclusion in the HIQR, HQQR, and EHR incentive/EH/CAH programs. (Submitted by: National Coalition for Hospice and Palliative Care)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16-167 - Safe Use of Opioids – Concurrent Prescribing: Patients ages 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge NASS agrees with MAP’s preliminary recommendation to not support this measure for rule-making at this time. In providing recommendations to CMS for further refinement of this measure, NASS would like to offer the following comments: - Measure Numerator/Denominator: o NASS questions how prescription use will be gleaned? From pharmacy records?  Also, how will the measure take into account the patient’s pre-procedure medication list?  - Exclusions: o NASS is concerned about the unintended consequences for surgeons treating post-operative pain in patients already on long-term benzodiazepines. To better account for these NASS strongly recommends that patients on baseline benzodiazepines or with complicated regimes of opioids are excluded from measure calculation. (Submitted by: North American Spine Society)

  • The Pharmacy Quality Alliance (PQA) supports the component of the measure, Safe Use of Opioids – Concurrent Prescribing (MUC16-167) that addresses concurrent prescribing of opioids and benzodiazepines. Several studies indicate that use of opioids and benzodiazepines together places patients at greater risk for fatal overdose.1-5 Three studies of fatal opioid overdose deaths found evidence of concurrent benzodiazepine use in 31%–61% of decedents.1-3 In one study, the rates of nonmedical use-related emergency department visits and overdose deaths involving both opioid analgesics and benzodiazepines approximately tripled from 2004 to 2011, and benzodiazepines were involved in 31% of opioid overdose deaths in 2011.2 Benzodiazepines were determined to be involved in 61% of opioid-related deaths in 2010 among North Carolina residents receiving prescription opioids.3 Furthermore, benzodiazepines are increasingly involved in opioid overdose deaths. The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly.4 Lastly, a case-cohort study found that concurrent use of benzodiazepines among US veterans using opioids raised the risk of drug overdose deaths nearly four-fold compared with patients not using benzodiazepines.5 The Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 recommendation is for clinicians to avoid prescribing opioid pain medications and benzodiazepines whenever possible (Category A recommendation [applies to all persons; most patients should receive the recommended course of action]; Type 3 evidence [observational studies or randomized clinical trials with notable limitation]).8 In addition, the US Food and Drug Administration recently added a boxed warning to the labeling of prescription opioid pain and cough and benzodiazepines products related to concurrent use of these medications.9 Despite the risks of severe respiratory depression and overdose, concurrent prescriptions for opioids and benzodiazepines is common and increasing.6,7 In one study, approximately half of the patients received both the opioid and benzodiazepine prescriptions from the same prescriber on the same day.6 In an analysis from 2015 in the non-cancer or non-hospice enrolled Medicare Part D opioid user population, the prevalence of opioid and benzodiazepine concurrent use was 24%.7 Although circumstances exist when it might be appropriate, concurrent use of opioids and benzodiazepines has an unfavorable balance of benefit and harm for most individuals. In summary, PQA is in strong support of that portion of the measure that addresses concurrent prescribing of opioids and benzodiazepines. 1. Gomes T, Mamdani MM, Dhalla I a, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686-691. doi:10.1001/archinternmed.2011.117. 2. Jones CM, McAninch JK. Emergency Department Visits and Overdose Deaths From Combined Use of Opioids and Benzodiazepines. Am J Prev Med. 2015;49(4):493-501. 3. Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality. Pain Med. September 2015. doi:10.1111/pme.12907. 4. Chen LH, Hedegaard H, Warner M. Drug-poisoning Deaths Involving Opioid Analgesics: United States, 1999-2011. NCHS Data Brief. 2014;(166):1-8. 5. Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert ASB. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics?: case-cohort study. :1-8. doi:10.1136/bmj.h2698. 6. Hwang CS, Kang EM, Kornegay CJ, Staffa JA, Jones CM, McAninch JK. Trends in the Concomitant Prescribing of Opioids and Benzodiazepines, 2002-2014. Am J Prev Med. 2016:1-10. doi:10.1016/j.amepre.2016.02.014. 7. CMS. Concurrent Use of Opioids and Benzodiazepines in a Medicare Part D Population. May 12, 2016. 2016. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Concurrent-Use-of-Opioids-and-Benzodiazepines-in-a-Medicare-Part-D-Population-CY-2015.pdf. Accessed December 6, 2016. 8. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1. 9. US Food and Drug Administration. FDA Drug Safety Communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. August 31, 2016. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm518473.htm. Accessed: November 9, 2016. (Submitted by: Pharmacy Quality Alliance)

  • The AHA cautiously agrees with the MAP’s recommendation to refine and resubmit this measure under the condition that the measure undergoes significant revision. The AHA supports the ongoing efforts to improve prescribing practices, but the design of the measure may be misguided for significant technical reasons. First, the measure assumes that concurrent prescriptions for opioids and benzodiazepines are always inappropriate. In fact, many patients come into a facility already on a prescription for a benzodiazepine, so terminating that prescription upon admission would result in serious harm to the patient as patients on those prescriptions must be “weaned” off over time. Instead of simply measuring the existence of concurrent prescriptions, this measure should evaluate new prescriptions where both types of drugs were simultaneously prescribed. Second, this e-measure presents additional technical issues. Providers who use e-prescribing to order an opioid or benzodiazepine prescription during the measurement period will have certified EHRs that are able to prescribe, send, and respond to the National Council for Prescription Drug Programs (NCPDP) Script transaction standards that support prescription change, cancel, refill, fill status notification, and medication history transaction of the prescriptions.  If the medications are not referenced in a consistent format or if there is an inconsistency in abbreviations to denote dose, then the ability to exchange the data is impeded by the inability of the systems to mutually understand and use the data that is exchange. In short, current technology and interoperability are not reliable enough to use for this measure. (Submitted by: The American Hospital Association)

Safe Use of Opioids – Concurrent Prescribing (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC16-167)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. Moreover, we believe the Workgroup’s discussion highlights the importance of achieving NQF endorsement prior to implementation in federal programs. We believe NQF endorsement is the best way to ensure that measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, consistent across types of health care providers, and responsive to variations in patient characteristics. Completing the NQF endorsement process can help address and resolve many of the important issues the Workgroup raised. (Submitted by: Adventist Health System)

  • AAHPM does not recommend the use of this measure. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • The NQF MAP recommended “do not support for rulemaking” MUC 16-167 Safe Use of Opioids – Concurrent Prescribing. The ACS disagrees with the MAPs recommends and supports “Refine and Resubmit Prior to Rulemaking,” with conditions submitted below. Beginning in the late 1990s, patient advocacy organizations began asking the medical community whether pain was being under-treated. In 1999, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, urging doctors to assess pain at every visit. Other major health care accreditation and regulatory authorities followed suit, including the Joint Commission. As a result, pain scores are now used as a quality measure, including in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. This has led to an increase in opioid medication prescribing when acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) fail. More than two decades later, physicians are still expected to treat this highly subjective “5th vital sign,” as patients often have the unreasonable expectation that they are to be pain free. The requirement to treat pain, along with a number of other factors, has led to a major increase in overuse, misuse, abuse, and diversion of these highly addictive medications. The ACS commends CMS on their current efforts to address the overuse of opioids with proposing MUC 16-167 for consideration in the Hospital Inpatient Quality Reporting Program and the Hospital Outpatient Quality Reporting Program. The Centers for Medicare & Medicaid Services (CMS) measure titled Safe Use of Opioids – Concurrent Prescribing (MUC 16-167) measures the proportion of patients ages 18 years and older with active, concurrent prescriptions for opioids or with active, concurrent prescriptions for an opioid and benzodiazepine at discharge. The intent of the measure is to reduce risk of respiratory depression, preventable mortality, and lower costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more different opioids or opioids and benzodiazepines concurrently. ACS asserts that the opioid public health problem must be a multifaceted approach involving all stakeholders, including policymakers on both the national and state level. We believe that the alignment of state mandates and federal guidelines on prescribing limits are critical. We think this alignment will help to address the opioid epidemic by making prescribing information available to all of a patient’s providers. We also strongly support efforts which will require states to have functioning Prescription Drug Monitoring Programs (PDMPs) that are interoperable with Electronic Health Records (EHRs); however, physicians’ utilization of PDMPs should remain voluntary. We support PDMP access for physicians, licenses independent practitioners (LIPs), physicians’ designated agents, and pharmacists. Additionally, we support the ability to e-prescribe and think it would be beneficial in cases of prescribing limits under 30 days in helping to reduce fraud. As stated, the NQF MAP reviewed this measure and recommended “Do Not Support for Rulemaking.” The NQF MAP did not support this measure because it believes there are many conditions where concurrent prescriptions are appropriate and expressed concern that patients may unintentionally suffer withdrawal symptoms if their prescriptions are reduced and/or stopped. Additionally, the NQF MAP noted that 2016 CDC Guideline for Prescribing Opioids for Chronic Pain are not evidence-based. The ACS disagrees with the NQF MAP’s recommendations and believes with further refinement this measure would be appropriate for rulemaking, pending NQF endorsement. We have reviewed the measure and recommend the inclusion of two additional measure exclusions/exceptions: • Exclusion for patients who are undergoing withdrawal therapy: To address one of the concerns of the NQF MAP-that patients may unintentionally suffer withdrawal symptoms if previously prescribed opioids and/or benzodiazepines are reduced and/or stopped prior to discharge-the ACS recommends an exclusion for patients who are undergoing withdrawal therapy. • Exception for postoperative and/or injured surgical patients when clinically appropriate: The CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 states that the use of opioids should be limited to =3–7 days. However, there are circumstances where more than 7 days of postoperative pain relief necessitating opioids is appropriate. In these circumstances, ACS supports an exception for postoperative and/or injured surgical patients beyond 7 days and up to a reasonable limit, based on the professional opinion of the attending physician. The ACS supports the existing exclusion from prescriber mandates included in this measure for patients undergoing cancer treatment and/or palliative care. “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016” n.d. Web. 13 Jan. 2017. Available at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. (Submitted by: American College of Surgeons)

  • (Submitted by: Center to Advance Palliative Care)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16-167 - Safe Use of Opioids – Concurrent Prescribing: Patients ages 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge NASS agrees with MAP’s preliminary recommendation to not support this measure for rule-making at this time. In providing recommendations to CMS for further refinement of this measure, NASS would like to offer the following comments: - Measure Numerator/Denominator: o NASS questions how prescription use will be gleaned? From pharmacy records?  Also, how will the measure take into account the patient’s pre-procedure medication list?  - Exclusions: o NASS is concerned about the unintended consequences for surgeons treating post-operative pain in patients already on long-term benzodiazepines. To better account for these NASS strongly recommends that patients on baseline benzodiazepines or with complicated regimes of opioids are excluded from measure calculation. (Submitted by: North American Spine Society)

  • Similarly to the IQR version of this measure, the AHA agrees with the committee’s decision to not support. In addition, there are other concerns about the characteristics of the patient population in the outpatient setting that would make this measure inappropriate. For example, this measure is not risk-adjusted (since it’s a process measure); that means that large referral centers with more complex and sicker patients may perform worse in this regard. Otherwise, we echo our comments on the IQR concurrent prescribing measure. (Submitted by: The American Hospital Association)

Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-178)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. Moreover, we believe the Workgroup’s discussion highlights the importance of achieving NQF endorsement prior to implementation in federal programs. We believe NQF endorsement is the best way to ensure that measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, consistent across types of health care providers, and responsive to variations in patient characteristics. Completing the NQF endorsement process can help address and resolve many of the important issues the Workgroup raised. (Submitted by: Adventist Health System)

  • The AHA agrees with the preliminary decision reached by the MAP to not support this measure. As with (MUC16-180), the AHA does not intend to trivialize the importance of treating drug and alcohol abuse; however, because of the lack of compelling evidence showing that this measure will lead to improved patient outcomes, this measure is not appropriate for implementation. The evidence that offering in-hospital interventions results in lowered rates of alcohol or drug abuse is limited. Indeed, the measure developers cite an ample volume of studies supporting the use of brief interventions, but many of those studies focus on the primary care setting. Because alcohol and drug abuse are chronic diseases, they often require much longer courses of care managed through a combination of outpatient providers, substance abuse treatment clinics, and others; thus, the primary care setting is often the most appropriate site for an intervention. In fact, the seminal Cochran study shows that these interventions only benefit heavy alcohol users, not light or average users. Furthermore, the observed change in alcohol use was only seen at the 6-9 month mark, not at the 1-year mark. Thus, these interventions involve significant effort for a small and not lifelong solution—and only for a subset of the denominator. These efforts would be particularly burdensome to rural or understaffed hospitals, which would find interventions difficult to carry out and operationalize across the facility.  Because there is a significant evidence gap regarding the cost of implementing the program as well as a lack of evidence showing improved patient outcomes, this measure is inappropriate for the hospital setting. (Submitted by: The American Hospital Association)

Alcohol Use Screening (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-179)
  • The AHA disagrees with the MAP’s recommendation to support this measure for rulemaking. The efforts necessary to implement alcohol use screenings are not tied to improved patient outcomes, and the measure itself only evaluates the processes taken rather than the substantive efforts to treat alcohol use disorders. During the workgroup discussion, some members suggested the use of the measure may help address the risks associated with alcohol toxicity and withdrawal for newly admitted patients. However, the evidence described to support the use of the measure articulates its potential link to lower rates of alcohol abuse, not to addressing alcohol toxicity. Furthermore, hospital providers already perform significant intake screenings that would identify a patient who used alcohol heavily enough that withdrawal from the substance would result in serious illness. Moreover, this measure only requires documentation that a screening was performed—it does not evaluate the quality of screening. There is a risk of the need to comply with this simplified measure replacing the more robust existing intake processes hospitals currently perform. In addition, this measure is not e-specified. Notwithstanding our significant misgiving about the accuracy and feasibility of eCQMs, we believe this type of screening measure may be best collected using data from EHRs. While the measure developer notes that SAMHSA is working with CMS to develop this measure into an eCQM, there is no timeline for when this will be completed. Thus, this measure requires efforts that are not shown to result in significant improvements in patient outcomes and should not be supported. (Submitted by: The American Hospital Association)

Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-180)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. Moreover, we believe the Workgroup’s discussion highlights the importance of achieving NQF endorsement prior to implementation in federal programs. We believe NQF endorsement is the best way to ensure that measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, consistent across types of health care providers, and responsive to variations in patient characteristics. Completing the NQF endorsement process can help address and resolve many of the important issues the Workgroup raised. (Submitted by: Adventist Health System)

  • While not pulled for discussion during the MAP workgroup meeting, the AHA wishes to reiterate the inappropriateness of this measure. The AHA acknowledges the importance of addressing drug and alcohol abuse, but believes that this particular measure is not based upon reliable data demonstrating improvement in patient outcomes as a result of its use. When this measure was submitted for endorsement by the NQF, the developer provided compelling evidence of the efficacy of prescription medication to treat alcohol and other drug use disorders. However, there is no evidence demonstrating improved outcomes from specifically prescribing these medications at discharge. Moreover, these medications are not indicated for every patient with the identified disorders; they can be very costly and may not be covered by insurance; many of these drugs (e.g. methadone for opioid dependence) have the potential for abuse—especially in the absence of careful, ongoing medical management. Because of the lack of evidence tying alcohol and other drug use disorder treatment provided at discharge to improved patient outcomes, in addition to the inherent complexities of medication therapy for alcohol and other drug use disorders, the AHA agrees with the NQF staff recommendation of no support. (Submitted by: The American Hospital Association)

Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-262)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need for the measure to be revised and resubmitted in order to better understand its overall impact on the quality of care. AHS agrees that improving the practice of informed consent may compliment efforts to encourage high-quality patient-centered decision making. We fully support the Workgroup’s recommendation that the measure be submitted to NQF for review and endorsement. We believe NQF endorsement is the best way to ensure that measures are indeed relevant to enhanced health outcomes, feasible and actionable for providers as well as complimentary to improved patient-centered decision-making. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, valid, verifiable, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs. (Submitted by: Adventist Health System)

  • The NQF MAP review the Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures (MUC 16-262) and voted to “Refine and Resubmit Prior to Rulemaking”. The ACS disagrees with the NQF MAP and recommends “Do Not Support for Rulemaking.” Background The Centers for Medicare & Medicaid Services (CMS) has developed a measure of informed consent document quality in order to “illuminate hospital-level quality, and to increase attention to informed consent processes in order to better support patients’ decisional needs, autonomy, and respect. ” As stated in the CMS Public Comment Summary Report , the goal of this measure is to support national strategies to promote patient-centered decision making. CMS notes that too often informed consent documents lack basic components such as information describing the procedure, associated risks and benefits, and alternative treatment options. In evaluating hospitals' informed consent document quality, CMS seeks to increase the attention and effort that hospitals dedicate to providing high-quality informed consent, thereby supporting patient autonomy. The ACS commends CMS on the goal of this measure and notes that that obtaining informed consent is sometimes viewed as a document signing event, in particular when the signature form is either highly generic or simple fill-in-the-blank forms that either lack specific details or are at a level beyond the understanding of the average patient and their family. The NQF MAP reviewed this measure and voted to “Refine and Resubmit Prior to Rulemaking,” recommending that the following refinements: 1) the measure be tested for reliability and validity at the facility level in the hospital setting, and 2) that the measure be submitted to NQF for review and endorsement. Additionally, the NQF MAP has concerns about the potential data collection burden associated with the measure. The ACS believes that the measure requires significant changes and therefore cannot support the current version of this measure. The ACS has carefully evaluated the measure, and recommends the below changes: 1. Inclusion of the ACS Surgical Risk Calculator In order to facilitate the informed consent discussion and to enable patient-centered decision making, ACS developed the ACS National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator. The ACS Surgical Risk Calculator is a patient-specific decision-support tool based on reliable multi-institutional clinical data, which can be used to estimate the patient’s risk for a specific operation (the calculator includes data on most operations). For more information on the ACS Risk Calculator, please visit http://riskcalculator.facs.org/RiskCalculator/. 2. Alignment with the ACS Statement on Principles on the topic of Informed Consent Because the surgeon is responsible for obtaining informed consent, we strongly encourage CMS to consider these principles in the refinement of the informed consent document quality measure to ensure that the measure aligns with the ACS principles: Informed consent is more than a legal requirement. It is a standard of ethical surgical practice that enhances the surgeon/patient relationship and that may improve the patient's care and the treatment outcome. Surgeons must fully inform every patient about his or her illness and the proposed treatment. The information must be presented fairly, clearly, accurately, and compassionately. The surgeon should listen carefully to understand the patient's feelings and wishes and should answer all questions as accurately as possible. The informed consent discussion conducted by the surgeon should include: 1. The nature of the illness and the natural consequences of no treatment. 2. The nature of the proposed operation, including the estimated risks of mortality and morbidity. 3. The more common known complications, which should be described and discussed. The patient should understand the risks as well as the benefits of the proposed operation. The discussion should include a description of what to expect during the hospitalization and post hospital convalescence. 4. Alternative forms of treatment, including nonoperative techniques. 5. A discussion of the different types of qualified medical providers who will participate in their operation and their respective roles. The surgeon should not exaggerate the potential benefits of the proposed operation nor make promises or guarantees. For minors and incompetent adults, parents or legal guardians must participate in the informed consent discussion and provide the signature for elective operations. Any adequately informed, mentally competent adult patient can refuse any treatment including operation. When mentally incompetent patients or the parents (guardians) of minors refuse treatments jeopardizing the patient's best interest, the surgeon can request legal assistance. When patients agree to an operation conditionally or make demands that are unacceptable to the surgeon, the surgeon may elect to withdraw from the case. 3. Measure at the Level of the Surgeon, Not the Hospital Informed consent is a critical aspect of a surgeon’s relationship with the patient and the surgeon is responsible for obtaining informed consent. Yet, the methodology measures informed consent at level of the hospital. ACS believes that this is a missed opportunity to enhance the surgeon/patient relationship and promote patient-centered decision-making. The responsibility for informed consent should be measured by the party whom is responsible for working with the patient to ensure comprehensive informed consent. 4. The Measure Should Capture the Informed Consent Discussion, Not Simply the Timing of Signing the Legal Document The NQF MAP acknowledged during their discussion that clinicians and patients have come to view the informed consent document as a transaction necessary for obtaining a signature of consent, rather than for information sharing or prompts for discussion. CMS notes in their Draft Measure Methodology Report that these quality gaps are “conflicting with the ethical and legal principles of informed consent. They do not support patient autonomy and often undermine the decisional process of informed consent.” To address these gaps in quality, ACS believes that the measure should be inclusive of the discussion of informed consent—when the decision to operate is being made—not simply when the legal documents are signed. For example, the informed consent discussion often takes place during moments after the decision to operate, when the procedure is scheduled. Or, the surgeon and patient may have had the informed consent discussion a week prior to the procedure, and the office staff may have had the informed consent signature on file in the office. In fact, in addition to a signed legal document, some states or hospitals require a surgeon’s chart note covering the elements of informed consent. In this case, the legal document may be executed separately and reflect the patient’s consent as obtained by nursing or other ancillary staff. Patients and surgeons would have two separate opportunities to engage in an informed consent process. It is also common that a patient requires a procedure and the surgeon has an unexpected opening and can schedule the patient the following day. The CMS measure assumes that there is only one workflow for obtaining informed consent, when there are multiple workflows and scenarios. 5. Streamline the Informed Consent Process with Interoperability The ACS agrees with the NQF MAP’s concern about the potential data collection burden associated with the measure, and strongly encourages the NQF MAP and CMS to realize need for the creation of standards for informed consent to streamline the flow of data with electronic health records (EHRs) and other data sources. Much of the work outlined in the Draft Measure Methodology Report includes the abstraction of data by trained abstractors which introduces the possibility of bias and creates additional burden on the provider or the hospital/office staff. Instead of a specific tool for informed consent, ACS sees many opportunities to streamline this process with digital workflows using an application program interface (APIs) in an open platform around EHRs. For example, this process could be included in the toolkits identified as part of the Office of the National Coordinator for Health Information Technology (ONC) Patient Engagement Playbook and joined with the ACS Surgical Risk Calculator as a tool for a more comprehensive and complete informed consent discussion. For more information on the Patient Engagement Playbook visit https://www.healthit.gov/playbook/pe/. 6. Simplify the Number of Elements in the Measure The final taxonomy of the proposed measure includes three domains, 20 dimensions, and 53 elements. ACS believes that this is far too many elements. We strongly encourage further testing with patients in an effort to capture only the elements that are most important and understandable to the patient. We also note that if the informed consent process in automated, as suggested above, this will be less of an issue. “Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures: Draft Measure Methodology Report for Public Comment” Yale New Haven Health Services Corporation – Center for Outcomes Research & Evaluation (YNHHSC/CORE). July, 2016. “Public Comment Summary Report” Centers for Medicare & Medicaid Services. n.d. Web. 13 Jan. 2017. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Informed-Consent-Document-Quality-Measure-Public-Comment-Summary-Report.pdf. (Submitted by: American College of Surgeons)

  • (Submitted by: American Institutes for Research)

  • Also need consideration of alternate methods, including supported decision-making (see http://supporteddecisionmaking.org/_ (Submitted by: Family Voices NJ)

  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16-262- Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures: This measure assesses the quality of informed consent documents for elective hospital-performed procedures for Medicare fee-for-service (FFS) patients. A sample of hospitals’ informed consent documents are evaluated using an instrument developed for this purpose. Hospital-level performance will be derived from aggregating these individual informed consent document quality scores.  - General Comments: o NASS does not believe that this measure is feasible or appropriate. Most physicians do not have control over the hospital's informed consent document.  The document being assessed still functions largely to mitigate legal liability.  The patient-centered, shared decision-making component of informed consent is a process that has very little to do with the actual informed consent document. NASS recommends that this measure be refocused to a measurement that is patient centric, such as patient retention of informed consent. (Submitted by: North American Spine Society)

  • The AHA supports efforts to improve the quality of informed consent. However, the proposed measure fails to add anything meaningful to such improvement efforts. Furthermore, hospitals are already held accountable for obtaining informed consent, so this measure does not add any new value. Thus, no amount of revision would result in this measure being useful or appropriate. Obtaining informed consent is certainly an activity that the AHA supports, and we have provided assistance to our members with best practices on the matter. CMS Conditions of Participation, Joint Commission standards, and various state laws and regulations already require informed consent; it is entirely unclear how this measure would make the consent process any more meaningful. In fact, this particular measure might be inconsistent with existing Conditions of Participation and interpretive guidance. Overall, this effort to develop a measure of informed consent seems divergent from any real opportunity to improve patient outcomes. Thus, the AHA does not see how this fits with the strategic and aligned set of measures. (Submitted by: The American Hospital Association)

Communication about Pain During the Hospital Stay (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-263)
  • Adventist Health System (AHS) supports MAP’s preliminary recommendation and rationale. It is our view that communication about pain during the hospital stay is an excellent measure concept and we are enthused by CMS’ interest in including this measure in future rulemaking. We commend the Workgroup for emphasizing the need to include non-pharmacological options used to treat pain. AHS completely agrees with the Workgroup’s recommendation that testing results demonstrate reliability and validity prior to implementation in the IQR program. Furthermore, we fully support the Workgroup’s recommendation that the measure be submitted to NQF for review and endorsement. We believe NQF endorsement is the best way to ensure that measures are indeed reliable and valid. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs, such as the IQR program. To be clear, AHS sees regular communication about pain as very important and we hope that this measure can be refined, resubmitted and endorsed in an expedient, yet considerate, manner so that it may be included future rulemaking. (Submitted by: Adventist Health System)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • Pain is a high priority when treating a patient and should be assessed frequently but should not be assessed as part of patient experience associated with a hospital stay. The questions are also extremely open ended and are not realistic since the scoring requires that the patient replies “Always” in order to get credit. The AMA also does not support the measure because the measure still includes questions 4 and 5. The workgroup was asked to only vote on questions 1, 2 and 3, but the preliminary recommendations still include questions 4 and 5 as part of the measure. The recommendations make no reference to the fact that CMS removed from voting questions 4 and 5. If you are a stakeholder who did not follow the in-person workgroup meeting and take the recommendations verbatim you would not recognize that CMS dropped questions 4 and 5. As drafted, it appears that questions 4 and 5 stand as is and the workgroup is only asking for questions 1, 2, and 3 to be revised and resubmitted prior to rulemaking. “The Workgroup recommended that this composite measure (HP1, HP2, and HP3) be revised and resubmitted prior to rulemaking because the measure has not undergone field testing and is intended to replace the Pain Management composite measure in the HCAHPS survey”. (Submitted by: American Medical Association)

  • (Submitted by: Center to Advance Palliative Care)

  • Thank you for the opportunity to comment on this important work. We believe that the focus of the HCAHPS Pain Management measures should be on patient engagement and communication/discharge teaching. We agree with the Hospitals workgroup recommendations that there be additional testing of the potential new pain management items to demonstrate reliability and validity before including in any pay-for-reporting program such as the Inpatient Quality Reporting (IQR) program. We also agree that any new pain composite measure should be submitted to NQF for review and endorsement prior to inclusion in any pay-for-reporting or pay-for-performance program. We would also suggest further emphasis on patient engagement and communication/discharge teaching. Our recommendations for additional pain management questions would include: 1. Did you receive any information about your pain treatment options? 2. Was the information about your pain care presented in a way you could understand? 3. Were you allowed to participate in decisions about your pain treatment as much as you wanted to? 4. Were you encouraged to use non-medicine methods in addition to any pain medicine that was needed? 5. Were you adequately prepared to understand how to manage your pain when you went home? (Submitted by: Harborview Medical Center)

  • I would like to add one more potential question to consider 5. Were you adequately prepared to understand how to manage your pain when you went home? (Submitted by: Individual/Chair of the American Pain Society's Special Interest Group on Quality)

  • The AHA commends CMS for its willingness to reexamine the pain management items in the HCAHPS survey as part of a multifaceted effort by the administration to address the opioid epidemic. However, we believe this measure needs significant refinement if it is to be included in hospital measurement. Pain management is of paramount importance to hospital patients, and under-treatment of pain carries enormous negative impacts to patient health and quality of life. However, the questions suggested for this survey need further revision to truly capture the patient experience. Appropriate “skip” logic must be incorporated to avoid excessive and irrelevant questioning; phrasing must be clarified so that a patient can suitably rate his/her level of understanding; the rating scale should provide options related to the patient’s preferences and needs rather than arbitrary time horizons like “always” and “never.” We note here that items HP4 and HP5 were removed from IQR and inserted in Value-Based Purchasing program with a recommendation of “Do Not Support.” The AHA agrees with this recommendation, as these questions regard medication therapy in a misleading and inappropriate manner. This line of questioning should include an evaluation of whether providers attempted non-medication pain management and questions that would result in better specificity about the manner of communication between providers and patients regarding pain levels. (Submitted by: The American Hospital Association)

Communication about Pain During the Hospital Stay (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC16-263)
  • Adventist Health System (AHS) supports MAP’s preliminary recommendation and rationale. It is our view that communication about pain during the hospital stay is an excellent measure concept and we are enthused by CMS’ interest in including this measure in future rulemaking. We commend the Workgroup pointing out the statutory requirement that measures be publicly reported for at least one year prior to being considered for adoption in the HVBP program. AHS believes that this lead time provides measurement authorities, such as the expert panels convened by NQF, time to review and, if necessary, refine measures before they are implemented in an even more substantially impactful program that directly and materially affects provider finances. In addition, we think the same issues the Workgroup raised, in its consideration of this measure for the IQR program, about the need to include non-pharmacological options used to treat pain are relevant to discussions about the proposed inclusion of this measure in the HVBP program. The Workgroup’s recommendation that testing results demonstrate reliability and validity prior to implementation in the IQR program are also relevant to any future consideration of this measure for use in the HVBP program. Furthermore, the results from any future use in the IQR program should inform any future consideration of including this measure in the HVBP program. We recommend that MAP also emphasize the need for this measure to achieve NQF endorsement prior to consideration for use in the HVBP program. We see NQF endorsement as the best way to ensure that measures are indeed reliable and valid. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, verifiable, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. To be clear, AHS sees regular communication about pain as very important and we hope that this measure can be refined, resubmitted and endorsed in an expedient, yet considerate, manner so that it may be included future rulemaking. (Submitted by: Adventist Health System)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • Pain is a high priority when treating a patient and should be assessed frequently but should not be assessed as part of patient experience associated with a hospital stay so we do not support the measure.The questions are also extremely open ended and are not realistic since the scoring requires that the patient replies “Always” in order to get credit. The AMA also does not support the measure because the measure still includes questions 4 and 5. The workgroup was asked to only vote on questions 1, 2 and 3, but the preliminary recommendations still include questions 4 and 5 as part of the measure. The recommendations make no reference to the fact that CMS removed from voting questions 4 and 5. If you are a stakeholder who did not follow the in-person workgroup meeting and take the recommendations verbatim you would not recognize that CMS dropped questions 4 and 5. As drafted, it appears that questions 4 and 5 stand as is and the workgroup is only asking for questions 1, 2, and 3 to be revised and resubmitted prior to rulemaking. “The Workgroup recommended that this composite measure (HP1, HP2, and HP3) be revised and resubmitted prior to rulemaking because the measure has not undergone field testing and is intended to replace the Pain Management composite measure in the HCAHPS survey”. (Submitted by: American Medical Association)

  • (Submitted by: Center to Advance Palliative Care)

  • I agree the proposed questions need further debate and revision. The proposed revisions still seem to focus too much on pain medication and asking if staff just asked about pain rather than focusing more on patients being engaged in a multimodal treatment plan including nonpharmacological interventions. Are HP1 (did you have pain) and HP4 (did you get medicine for pain) necessary to screen for patient to answer subsequent questions??? I would suggest the following questions be considered: Engagement and communication Did you receive any information about your pain treatment options? Was the information about your pain care presented in a way you could understand? Were you allowed to participate in decisions about your pain treatment as much as you wanted to? Were you encouraged to use non-medicine methods in addition to any pain medicine that was needed? (Submitted by: Individual/Chair of the American Pain Society's Special Interest Group on Quality)

  • We recommend the use of this measure for the HIQR and HVBP programs however we recommend this be refined and resubmitted prior to rulemaking. (Submitted by: National Coalition for Hospice and Palliative Care)

Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-269)
  • Incorporation of MUC16-269 would add value to the MIPS program by identifying and reducing the inappropriate, ineffective, and potentially harmful use of systemic antimicrobials for otitis media with effusion, which have been demonstrated to have no long-term benefit in the vast majority of cases, and may cause potential adverse effects.   The use of this measure would improve patient outcomes through the reduction of the use of an inappropriate and ineffective medical intervention, and avoidance of potential adverse effects of inappropriate therapy.  The Academy feels the benefits of this measure strongly outweigh any potential data collection burden.  In 2016, Roditi et al. found that data from 1,390,404,196 pediatric visits demonstrated that oral antibiotics were administered for 32% of visits with an OME diagnosis, even in the absence of acute otitis media.  This measure has been incorporated into the AAO-HNSF clinical data registry, and required data elements can be captured directly from a practice’s EHR by our registry.  We anticipate little to no data collection burden for this measure when reported in a registry environment.  [Roditi RE, Liu CC, Bellmunt AM, Rosenfeld RM, Shin JJ. Oral Antibiotic Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement.Otolaryngol Head Neck Surg. 2016 May;154(5):797-803.] (Submitted by: American Academy of Otolaryngology - Head and Neck Surgery)

  • Support the measure: The use of this measure would improve patient outcomes through the reduction of the use of an inappropriate and ineffective medical intervention, and avoidance of potential adverse effects of inappropriate therapy. The use of systemic antimicrobials for otitis media with effusion have demonstrated no long-term benefit in the vast majority of cases, and may cause potential adverse effects. (Submitted by: American Medical Association)

Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-271)
  • As noted in previous comment letters, a stronger emphasis on cancer-specific outcome measures would be more valuable to our efforts to improve the quality and value of patient care at our institutions. We support the MAP’s alignment with this perspective, evidenced most recently by its strong support for the adoption of cancer-specific end of life measures for our program.  We appreciate the MAP’s other recommendations for the PCHQR Program (e.g., development of measures of global harm in the inpatient setting and informed consent) and would gladly partner with CMS, NQF, and others to explore the development of such measures.  • We support adoption of this measure and agree with the MAP’s decision, as this measure can help identify opportunities to ensure that care delivery at the end of life aligns with patient preferences.  • In the future, we encourage the measure developer to consider modification of the measure to ensure that the measure does not discourage chemotherapy delivered for palliation (e.g., for painful bone metastases) along with patients on clinical trials. (Submitted by: Alliance of Dedicated Cancer Centers)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • (Submitted by: Center to Advance Palliative Care)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

  • Oncology care that aligns with patient preferences and appropriate utilization of end-of-life care are high priorities for MD Anderson and other PCHs.  All too often, Americans with advanced disease receive overly aggressive treatment where the treatment toxicities outweigh the potential clinical benefits.  Likewise, patients often lack adequate and timely access to palliative care and hospice care, leading to diminished quality of life and increased healthcare costs at the end of life.   Early access to palliative care services and timely hospice referral can ease the burden of cancer, improving symptom management and quality of life while reducing healthcare utilization and spending.  Likewise, timely advance care planning is critical to aligning treatment plans with patient values and preferences for treatment intensity, life-prolonging treatment, and quality of life.  Appropriate utilization of care at the end of life is an important indicator of high-quality cancer care.  Thus, the ADCC proposed for voluntary reporting within the PCHQR four endorsed end-of-life measures endorsed by the National Quality Forum (NQF): • Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (MUC16-271); • Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (MUC16-273); • Proportion of patients who died from cancer admitted to hospice for less than 3 days (MUC16-274); and, • Proportion of patients who died from cancer not admitted to hospice (MUC16-275). The PCHQR represents an excellent venue in which to increase transparency around these important indicators.  We appreciate the MAP’s support for these measures and agree with the MAP’s recommendation to pair Proportion of patients who died from cancer admitted to hospice for less than 3 days (MUC16-274) and Proportion of patients who died from cancer not admitted to hospice (MUC16-275) to better understand hospice referral patterns.  In the future, we encourage the measure developer to incorporate within the measure hospital-based palliative care services.  Hospital-based palliative care offers excellent symptom management and improves quality of life while allowing patients to receive services (e.g., palliative radiation therapy) that are often unavailable due to hospice benefit design.  (Submitted by: The University of Texas MD Anderson Cancer Center)

Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-273)
  • Please see previous comments submitted for MUC16-271. • We support adoption of this measure and agree with the MAP’s decision, as this measure can help identify opportunities where patients may require additional supportive care and appropriate transition to palliative care and hospice services. • In the future, we encourage the measure developer to evaluate ICU admission at outside hospitals using broad Medicare and/or private payer datasets.  Examining ICU admissions to the treating hospital vs. outside hospitals could provide important insights regarding ICU admission patterns and ways to improve performance on this measure.  (Submitted by: Alliance of Dedicated Cancer Centers)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • (Submitted by: Center to Advance Palliative Care)

  • MUC16-273 -- Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life. We recommend, in addition to adoption of this measure, that NQF explore with potential developers and the original measure steward the opportunity for adopting a version of this measure for which the denominator is not limited to cancer patients. (Submitted by: Compassion & Choices)

  • (Submitted by: National Coalition for Hospice and Palliative Care)

  • The AHA believes these measures regarding the proportion of patients who died from cancer receiving inappropriate acute care at the end of their lives need further refinement before they are incorporated into quality measurement. End-of-life care is paramount to cancer patients, particularly those with aggressive forms of cancer whose prognoses are not promising; however, the AHA has both technical and conceptual concerns with these measures. Technically, the concern is that these measures are at the physician level rather than the facility level; in fact, it appears that these measures have not yet been tested at the facility level, so testing must be completed before they are implemented in a facility-level quality measurement program. While we acknowledge that these measures apply to a small number of providers—i.e. the 11 cancer center hospital systems under the PPS-exempt Cancer Hospital Quality Reporting program—the AHA still believes that there is a difference between measuring the quality of individual clinician decision-making and the quality of facility care. Conceptually, these measures do appear to target the right kinds of inappropriate care at the end of life, including the use of ICUs, chemotherapy, and lack of hospice care. However, there appear to be virtually no exclusions in the measure specifications that would account for patient and family preferences. In order to fairly and accurately reflect the difficult balance between providing clinically appropriate and culturally sensitive care, such exclusions must be incorporated to ensure the reporting of the measure does not promote care inconsistent with patient and family preferences. (Submitted by: The American Hospital Association)

  • Please see the comments submitted for MUC16-271. (Submitted by: The Unversity of Texas MD Anderson Cancer Center)

  • Understood that there is value in recommending hospice and end of life care for some cancer patients, this measure, however, being linked to payment, has the enormous potential to encourage hospitals and practitioners to deny the provision of intensive care. There are advanced cancer patients who survive a period of ICU hospitalization and go on to lead valuable if shortened lives. There is no evidence of consideration of any type of balancing factor in this recommendation. As it stands this, and similar measures 271, 274 and 275, are reckless and court clinical behaviors which will potentially deprive reasonable ICU care for cancer patients. Linking such measures to payment, without any balancing factors, is a disturbing journey on which to embark. I am no fan of terminal cancer patients being subjected to endless invasive procedures in an ICU, but measures such as this, without any effort to identify proper balancing factors, run the real risk of diminishing the value of lives. As above. (Submitted by: University of North Carolina Chapel Hill Department of Pediatrics)

Proportion of patients who died from cancer admitted to hospice for less than 3 days (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-274)
  • Please see previous comments submitted for MUC16-271 • We support adoption of this measure and agree with the MAP’s decision, as this measure can help identify opportunities for advance care planning and earlier transition to hospice care. • We support pairing of this measure with MUC16-275. • In the future, we encourage the measure developer to consider expansion of this measure to include hospital-based palliative care services, which can offer excellent symptom management while allowing patients to receive services that are unavailable due to hospice benefit design. (Submitted by: Alliance of Dedicated Cancer Centers)

  • AAHPM recommends the use of measures MUC16-274 and MUC16-275 for the PCHQR quality reporting programs, but with the stipulation that they be considered a measure pair - ie, that implementation of one measure without the other is not acceptable. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • (Submitted by: Center to Advance Palliative Care)

  • MUC16-274 – Proportion of patients who died from cancer admitted to hospice for less than 3 days. We recommend, in addition to adoption of this measure, that NQF explore with potential developers and the original measure steward the opportunity for adopting a version of this measure for which the denominator is not limited to cancer patients. We understand that the MAP has previously recommended this action and would like to receive an update on the status of the MAP’s previous recommendation. (Submitted by: Compassion & Choices)

  • The National Coalition for Hospice and Palliative Care recommends the use of measures MUC16-274 and MUC-275 for the PCHQR quality reporting programs but with the stipulation that they be considered a measure pair - ie: that implementation of one measure without the other is unacceptable. (Submitted by: National Coalition for Hospice and Palliative Care)

  • The AHA believes these measures regarding the proportion of patients who died from cancer receiving inappropriate acute care at the end of their lives need further refinement before they are incorporated into quality measurement. End-of-life care is paramount to cancer patients, particularly those with aggressive forms of cancer whose prognoses are not promising; however, the AHA has both technical and conceptual concerns with these measures. Technically, the concern is that these measures are at the physician level rather than the facility level; in fact, it appears that these measures have not yet been tested at the facility level, so testing must be completed before they are implemented in a facility-level quality measurement program. While we acknowledge that these measures apply to a small number of providers—i.e. the 11 cancer center hospital systems under the PPS-exempt Cancer Hospital Quality Reporting program—the AHA still believes that there is a difference between measuring the quality of individual clinician decision-making and the quality of facility care. Conceptually, these measures do appear to target the right kinds of inappropriate care at the end of life, including the use of ICUs, chemotherapy, and lack of hospice care. However, there appear to be virtually no exclusions in the measure specifications that would account for patient and family preferences. In order to fairly and accurately reflect the difficult balance between providing clinically appropriate and culturally sensitive care, such exclusions must be incorporated to ensure the reporting of the measure does not promote care inconsistent with patient and family preferences. (Submitted by: The American Hospital Association)

  • Please see the comments submitted for MUC16-271. (Submitted by: The University of Texas MD Anderson Cancer Center)

Proportion of patients who died from cancer not admitted to hospice (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-275)
  • Please see previous comments submitted for MUC16-271 • We support adoption of this measure and agree with the MAP’s decision, as this measure can help identify opportunities to ensure appropriate transition to hospice care and advance care planning. • We support pairing of this measure with MUC16-274. • In the future, we encourage the measure developer to consider expansion of this measure to include hospital-based palliative care services, which can offer excellent symptom management while allowing patients to receive services that are unavailable due to hospice benefit design. This is especially important for patients that are seeking access to life-prolonging clinical trials, which would be unavailable to hospice enrollees. (Submitted by: Alliance of Dedicated Cancer Centers)

  • AAHPM recommends the use of measures MUC16-274 and MUC16-275 for the PCHQR quality reporting programs, but with the stipulation that they be considered a measure pair - ie, that implementation of one without the other is not acceptable. (Submitted by: American Academy of Hospice and Palliative Medicine)

  • (Submitted by: Center to Advance Palliative Care)

  • MUC16-275 -- Proportion of patients who died from cancer not admitted to hospice. We recommend, in addition to adoption of this measure, that NQF explore with potential developers and the original measure steward the opportunity for adopting a version of this measure for which the denominator is not limited to cancer patients. (Submitted by: Compassion & Choices)

  • The AHA believes these measures regarding the proportion of patients who died from cancer receiving inappropriate acute care at the end of their lives need further refinement before they are incorporated into quality measurement. End-of-life care is paramount to cancer patients, particularly those with aggressive forms of cancer whose prognoses are not promising; however, the AHA has both technical and conceptual concerns with these measures. Technically, the concern is that these measures are at the physician level rather than the facility level; in fact, it appears that these measures have not yet been tested at the facility level, so testing must be completed before they are implemented in a facility-level quality measurement program. While we acknowledge that these measures apply to a small number of providers—i.e. the 11 cancer center hospital systems under the PPS-exempt Cancer Hospital Quality Reporting program—the AHA still believes that there is a difference between measuring the quality of individual clinician decision-making and the quality of facility care. Conceptually, these measures do appear to target the right kinds of inappropriate care at the end of life, including the use of ICUs, chemotherapy, and lack of hospice care. However, there appear to be virtually no exclusions in the measure specifications that would account for patient and family preferences. In order to fairly and accurately reflect the difficult balance between providing clinically appropriate and culturally sensitive care, such exclusions must be incorporated to ensure the reporting of the measure does not promote care inconsistent with patient and family preferences. (Submitted by: The American Hospital Association)

  • Please see the comments submitted for MUC16-271. (Submitted by: The University of Texas MD Anderson Cancer Center)

Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-291)
  • The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List-Round 2. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.   MUC16-291- Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS): The original S-CAHPS survey, as part of the surgical patient experience battery, were designed by the American College of Surgeons (ACS) and the Surgical Quality Alliance (SQA) to address the specific needs of surgical patients. The 6 composites and 1 single-item measure were endorsed by the CAHPS Consortium in 2010 and by the National Quality Forum (NQF) in 2012. Each composite and/or grouping is used to assess a particular domain of patient experience with surgical care quality, from the patient’s perspective.  This entry combined 7 measures into one MUC List entry.  They are 7 separate measures (6 composite and 1 single item measure).  - General Comments: o NASS does not support MAP’s preliminary recommendation to include this measure in the MIPS program.  NASS believes that patient experience and satisfaction should not be used for accountability purposes as these are often subjective in nature, often not directly under the control of the physician (e.g., physician wait times in a hospital setting), and not necessarily true indicators of quality. Spine care providers see many patients with chronic pain, and some of these patients may not respond to surgical intervention. Often times, their level of pain will determine their patient satisfaction and have little to do with the overall experience and quality of care provided. - Data Acquisition and Entry: o As required with other CAHPS measures in Medicare quality reporting programs, will users be required to contract with a CMS approved vendor to submit data? Or how will data be submitted/ who will be responsible for costs? (Submitted by: North American Spine Society)

Completion of a Malnutrition Screening within 24 Hours of Admission (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-294)
  • Screening is a critical first step in appropriate malnutrition care. Malnutrition is a condition that remains underdiagnosed and untreated, especially for older adult patients. Up to 39% of hospitalized older adults are malnourished, , leading to increased mortality, longer lengths of stay, higher readmissions rates, and greater complications. , , , Screening upon admission with a validated tool is a low-burden way to identify patients at-risk for poorer outcomes due to their nutritional status and initiate appropriate care. For example, there are multiple scientifically validated tools that contain simple questions and produce easy-to-understand results with which nurses, diet technicians, or dietitians can determine whether the patient requires further assessment and intervention. , , Screening forms the foundation for all subsequent hospital-based nutrition care, including a thorough dietitian assessment, diagnosis, nutrition support, and ongoing monitoring. Without screening, patients who are malnourished or at-risk of malnutrition may go unrecognized and remain untreated. Given how nutrition care is provided in the hospital, the numerator for this measure (number of patients identified as at-risk of malnutrition) becomes the denominator for the subsequent nutrition assessment measure. Lack of use of this measure may lead to artificially high nutrition assessment results reported, as the denominator will only include those patients that a clinician flags as at-risk without systematic identification of patient risk. Recently published data continues to support the case for addressing malnutrition in the hospital. Malnourished patients tend to be older, have up to 100% longer lengths of stay, and have 100% costlier episodes of inpatient care. They are also half as likely to be discharged home and 4.9 times more likely to result in in-hospital death than the average of all inpatient nonmaternal/non-neonatal stays. Consequently, the economic impact of malnutrition in the hospital is estimated to be $42 billion. Furthermore, an additional report by AHRQ indicated that the 30-day readmission rate for malnourished patients was 23 per 100, compared with 14.9 per 100 without malnutrition. Costs were also 26% higher for readmissions involving patients with malnutrition than average readmissions without malnutrition. Global research published in the last five years also confirms these findings, highlighting that malnutrition risk affects three in five hospitalized patients and is associated with increased mortality and costs8, as well as greater LOS and readmission rates. It is also associated with adverse clinical outcomes, decreased functional status, and higher costs. , , , , We believe that the recommendation to complete malnutrition screening should be widely adopted in line with best practice guidelines to target and decrease the negative impact of malnutrition. , , , , Therefore, we urge the Committee to acknowledge the evidence brought forth in these comments and move towards consensus endorsement of this measure of malnutrition screening for hospitalized patients. Screening is a critical first step in appropriate malnutrition care. Malnutrition is a condition that remains underdiagnosed and untreated, especially for older adult patients. Up to 39% of hospitalized older adults are malnourished, , leading to increased mortality, longer lengths of stay, higher readmissions rates, and greater complications. , , , Screening upon admission with a validated tool is a low-burden way to identify patients at-risk for poorer outcomes due to their nutritional status and initiate appropriate care. For example, there are multiple scientifically validated tools that contain simple questions and produce easy-to-understand results with which nurses, diet technicians, or dietitians can determine whether the patient requires further assessment and intervention. , , Screening forms the foundation for all subsequent hospital-based nutrition care, including a thorough dietitian assessment, diagnosis, nutrition support, and ongoing monitoring. Without screening, patients who are malnourished or at-risk of malnutrition may go unrecognized and remain untreated. Given how nutrition care is provided in the hospital, the numerator for this measure (number of patients identified as at-risk of malnutrition) becomes the denominator for the subsequent nutrition assessment measure. Lack of use of this measure may lead to artificially high nutrition assessment results reported, as the denominator will only include those patients that a clinician flags as at-risk without systematic identification of patient risk. Recently published data continues to support the case for addressing malnutrition in the hospital. Malnourished patients tend to be older, have up to 100% longer lengths of stay, and have 100% costlier episodes of inpatient care. They are also half as likely to be discharged home and 4.9 times more likely to result in in-hospital death than the average of all inpatient nonmaternal/non-neonatal stays. Consequently, the economic impact of malnutrition in the hospital is estimated to be $42 billion. Furthermore, an additional report by AHRQ indicated that the 30-day readmission rate for malnourished patients was 23 per 100, compared with 14.9 per 100 without malnutrition. Costs were also 26% higher for readmissions involving patients with malnutrition than average readmissions without malnutrition. Global research published in the last five years also confirms these findings, highlighting that malnutrition risk affects three in five hospitalized patients and is associated with increased mortality and costs8, as well as greater LOS and readmission rates. It is also associated with adverse clinical outcomes, decreased functional status, and higher costs. , , , , We believe that the recommendation to complete malnutrition screening should be widely adopted in line with best practice guidelines to target and decrease the negative impact of malnutrition. , , , , Therefore, we urge the Committee to acknowledge the evidence brought forth in these comments and move towards consensus endorsement of this measure of malnutrition screening for hospitalized patients. Screening is a critical first step in appropriate malnutrition care. Malnutrition is a condition that remains underdiagnosed and untreated, especially for older adult patients. Up to 39% of hospitalized older adults are malnourished, , leading to increased mortality, longer lengths of stay, higher readmissions rates, and greater complications. , , , Screening upon admission with a validated tool is a low-burden way to identify patients at-risk for poorer outcomes due to their nutritional status and initiate appropriate care. For example, there are multiple scientifically validated tools that contain simple questions and produce easy-to-understand results with which nurses, diet technicians, or dietitians can determine whether the patient requires further assessment and intervention. , , Screening forms the foundation for all subsequent hospital-based nutrition care, including a thorough dietitian assessment, diagnosis, nutrition support, and ongoing monitoring. Without screening, patients who are malnourished or at-risk of malnutrition may go unrecognized and remain untreated. Given how nutrition care is provided in the hospital, the numerator for this measure (number of patients identified as at-risk of malnutrition) becomes the denominator for the subsequent nutrition assessment measure. Lack of use of this measure may lead to artificially high nutrition assessment results reported, as the denominator will only include those patients that a clinician flags as at-risk without systematic identification of patient risk. Recently published data continues to support the case for addressing malnutrition in the hospital. Malnourished patients tend to be older, have up to 100% longer lengths of stay, and have 100% costlier episodes of inpatient care. They are also half as likely to be discharged home and 4.9 times more likely to result in in-hospital death than the average of all inpatient nonmaternal/non-neonatal stays. Consequently, the economic impact of malnutrition in the hospital is estimated to be $42 billion. Furthermore, an additional report by AHRQ indicated that the 30-day readmission rate for malnourished patients was 23 per 100, compared with 14.9 per 100 without malnutrition. Costs were also 26% higher for readmissions involving patients with malnutrition than average readmissions without malnutrition. Global research published in the last five years also confirms these findings, highlighting that malnutrition risk affects three in five hospitalized patients and is associated with increased mortality and costs8, as well as greater LOS and readmission rates. It is also associated with adverse clinical outcomes, decreased functional status, and higher costs. , , , , We believe that the recommendation to complete malnutrition screening should be widely adopted in line with best practice guidelines to target and decrease the negative impact of malnutrition. , , , , Therefore, we urge the Committee to acknowledge the evidence brought forth in these comments and move towards consensus endorsement of this measure of malnutrition screening for hospitalized patients. (Submitted by: Academy of Nutrition and Dietetics)

  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need for the measure to be revised and resubmitted in order to ensure it is evidence-based. We fully support the Workgroup’s recommendation that the measure be submitted to NQF for review and endorsement. We believe NQF endorsement is the best way to ensure that measures are indeed evidence-based. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs. (Submitted by: Adventist Health System)

  • The AHA disagrees with the MAP’s recommendation to refine and resubmit this measure and instead suggests that it not be supported. This measure has not completed field testing, and this measure has not been endorsed by the NQF committee on the basis that it fails the evidence criterion. (Submitted by: The American Hospital Association)

Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 Hours of a Malnutrition Screening (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-296)
  • We commend the Workgroup’s decision to conditionally support MUC16-296 for inclusion in the IQR pending NQF endorsement.  Malnutrition is a patient-safety risk and an independent predictor of negative patient outcomes including mortality, length of hospital stay, readmissions, and hospitalization cost.  Malnourished patients are also more likely to develop pressure ulcers, infections, post-operative complications and experience falls.  The Subjective Global Assessment (SGA), handgrip strength and food intake have all been found to be independent predictors of poor outcomes in malnourished patients.  In a recent prospective, randomized, double-blind, placebo-controlled, multicenter study of 652 hospitalized malnourished older adults clinicians saw a significant reduction in post-discharge outcomes; i.e., 30, 60, and 90-day mortality (>50% reduction) and significant improvement in nutritional status (handgrip strength and weight gain) when patients were assessed and diagnosed using the SGA and then received nutrition intervention with a specialized oral nutritional supplement.  No effects of the intervention were observed for the primary composite endpoint of non-elective readmission or death at 90 days (Deutz et al. Clinical Nutrition 35 2016).  We agree with the report that inclusion of MUC16-296 is an important first step to fill the gap and to provide value to the measure set by improving quality of care for patients.  The assessment guides diagnoses, interventions, and care plans to address the patient’s malnutrition and to prevent nutritional decline. (Submitted by: Abbott)

  • completed for all patients at-risk for malnutrition. Results of the assessment are the primary source of information for other clinicians regarding the patient’s nutritional status and signs of malnutrition. In turn, it guides diagnoses, recommendations for interventions, and care plans to address the patient’s malnutrition and prevent nutritional decline. , , , Often, clinicians will begin a discharge plan using the nutrition assessment. Stakeholders such as The Joint Commission have acknowledged the importance of nutrition assessments for at-risk patients by including the practice in their Provision of Care standards (PC.01.02.01, EP 2) for hospital evaluation. This measure is the second in a suite of measures to support evidence-based care for malnutrition, outlining the malnourished patient’s necessary plan for intervention. Existing guidelines recommend nutrition assessment as a best practice, and new evidence has recently emerged highlighting the importance of nutrition assessments for patients at-risk of malnutrition. , , , , Malnutrition is a highly prevalent healthcare condition that often goes undiagnosed and untreated. Although rates of malnutrition among hospitalized older adults are as high as 39%, , a recent AHRQ report on malnutrition-involved discharges indicates that only 7.1% of discharges in U.S. hospitals have a malnutrition diagnosis coded in their medical record. Moreover, a survey of 1,700 providers of nutrition care in the hospital found that in 40% of participating hospitals, clinicians are missing 50% of their patients who screened positive for malnutrition risk. Further, only 26% of providers are always basing their diagnosis of malnutrition for patients on nutrition assessments. The impact of malnutrition on patients and the healthcare system is significant. Malnourished patients are half as likely to be discharged home from a hospital, 4.9 times more likely to die in the hospital, have up to 100% longer lengths of stay, and cost twice the average inpatient stay. Thus higher healthcare costs from disease-related malnutrition in the U.S. are $157 billion, with $51.3 billion attributed to those age 65 years and older. Additionally a new AHRQ statistical brief indicated that the 30-day readmission rate for malnourished patients was 54.6% higher compared to those without malnutrition. (Submitted by: Academy of Nutrition and Dietetics)

  • The Academy and Avalere would like to commend the MAP Hospital Workgroup’s decision to conditionally support MUC16-296 for inclusion pending NQF endorsement. The nutrition assessment is a thorough, systematic approach to evaluate a patient’s nutrition status and should be completed for all patients at-risk of malnutrition. Results of the assessment conducted by a registered dietitian provide the primary source of information for other clinicians (e.g., physicians, nurses, pharmacists) regarding the patient’s nutritional status, clinical indicators of malnutrition to inform diagnoses, and recommendations regarding interventions and care plans to address the patient’s malnutrition (or malnutrition risk) and prevent further nutritional decline.[1,2,34] Often, clinicians will also initiate a discharge plan based on the nutrition assessment. Stakeholders such as The Joint Commission have acknowledged the importance of completing nutrition assessments for at-risk patients by including the practice in their Provision of Care standards (PC.01.02.01, EP 2) for hospital evaluation.[5] The impact of malnutrition is significant, both in terms of patient outcomes and economic costs. This patient cohort tends to be older, have up to 100% longer lengths of stay, is twice as costly episodes of care, are half as likely to be discharged home, and are 4.9 times more likely to result in in-hospital death than the average of all inpatient nonmaternal/non-neonatal stays. In turn, hospital stays involving malnutrition cost the system approximately $42 billion annually.[6] The total cost associated with disease-related malnutrition in the U.S. increases to $157 billion when accounting for morbidity, mortality, and direct medical costs.[7] References: [1] Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2016; http://dx.doi.org/10.1016/j.clnu.2016.09.004. [2] British Association for Parenteral and Enteral Nutrition. Malnutrition Matters, A Toolkit for Clinical Commissioning Groups and providers in England. Published 2012. Retrieved from: http://www.bapen.org.uk/pdfs/bapen_pubs/bapen-toolkit-for-commissioners-and-providers.pdf. [3] Academy of Nutrition & Dietetics. CI: Nutrition Assessment of Critically Ill Adults 2012. Academy of Nutrition & Dietetics Evidence Analysis Library. Published 2012. Retrieved from: http://www.andeal.org/topic.cfm?menu=4800. [4] White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83. [5] Standards information for hospitals. The Joint Commission. https://www.jointcommission.org/accreditation/hap_standards_information.aspx. Accessed October 11, 2016. [6] Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.pdf. [7] Snider J, et al: Economic burden of community-based disease-associated malnutrition in the United States. JPEN J Parenteral Enteral Nutr. 2014;38:55-165. (Submitted by: Academy of Nutrition and Dietetics & Avalere Health)

  • We commend the Workgroup’s decision to conditionally support MUC16-296 for inclusion in the HIQR pending NQF endorsement. As malnutrition continues to be prevalent and costly in hospitalized older adults we agree with the workgroup report that inclusion of a nutrition assessment measure could help fill the gap on malnutrition and provide value to improving quality of care for patients. The significant impact of malnutrition on patients and the healthcare system was recently highlighted in an AHRQ HCUP analysis where they found that malnourished inpatients tend to be older, are 5 times more likely to result in in-hospital death, have up to two times longer lengths of stay, can have significant increases in episode costs (up to $25,000) and hospital 30-day readmissions are 54% higher than non-malnourished patients.¹,² The assessment is a critical component as it guides diagnoses, recommendations for interventions, and care plans to address the patient’s malnutrition and prevent nutritional decline. Results of the assessment are the primary source of information for other clinicians regarding the patient’s nutritional status and signs of malnutrition. ¹Weiss AJ et al. AHRQ HCUP Statistical Brief #210. September 2016. ²Fingar KR et al. AHRQ HCUP Statistical Brief #218. December 2016. (Submitted by: AdvaMed)

  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need to ensure it is evidence-based. We believe NQF endorsement is the best way to ensure that measures are indeed evidence-based. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs. (Submitted by: Adventist Health System)

  • We commend the Workgroup’s recommendation to conditionally support MUC16-296 for inclusion pending NQF endorsement. The prevalence of malnutrition in older adults is a growing concern because this health condition often goes undiagnosed and unrecognized, resulting in costly and sometimes fatal health outcomes. Malnutrition rates among hospitalized older adults are estimated to be as high as 39%,[1], [2] and can be caused by acute or chronic illness, injury, food insecurity or other psycho social determinants. Age, physical trauma, prolonged bed rest, and the stress of disease, surgery, or infection can all increase loss of the body’s muscle and protein stores and further increase the risk for malnutrition. While many factors can impact the health and well-being of older adults, malnutrition is a condition that is linked to increased incidences of falls, hospital admissions and readmissions, chronic disease, co-morbid health conditions, psychological stress, slowed recovery and decreased independence. The estimated annual cost of disease-associated malnutrition in older adults is $51.3 Billion. It is essential for the healthcare team to assess malnutrition while patients are in the hospital in order to expedite healing, offer on-site nutrition interventions and education, and provide a plan for ongoing nutritional support. Inclusion of MUC16-296 will help provide value by improving quality of care and outcomes for patients. ¹Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-8. ²Pereira GF, Bulik CM, Weaver MA, Holland WC, Platts-mills TF. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med. 2015;65(1):85-91. (Submitted by: Defeat Malnutrition Today)

  • (Submitted by: Healthcare Nutrition Council)

  • Medtronic’s Minimally Invasive Therapies Group supports efforts to identify patients at-risk for malnutrition so that an appropriate and timely plan of care can be implemented for all Medicare beneficiaries. It was noted among NQF materials that based on a national survey of hospital-based professionals in the United States focused on nutrition screening and assessment practices, out of 1,777 unique respondents, only 36.7% reported completing nutrition screening at admission, and 50.8% reported doing so within 24 hours. Only 69% reported documenting the findings in the medical record. Given the disparity of care among Medicare beneficiaries who currently receive appropriate and timely access to a nutritional assessment and care, we would support this measure to ensure timely access to nutritional support for all Medicare beneficiaries. We recognize that the Workgroup supported this measure for rulemaking with the condition that NQF's Health and Well-Being Standing Committee agrees that the evidence supporting this measure meets the Evidence criterion and the measure receives NQF endorsement. (Submitted by: Medtronic- Minimally Invasive Therapies Group)

  • There should not be an age disparity between MUC16-294 (malnutrition screening for all inpatients age 18 and up) and MUC16-296 (nutrition assessment for patients age 65 and up found to be at-risk on screening).  The age cutoff should be 18 for both, or 65 for both.  Otherwise you might do a disservice to all malnourished 18-64 year olds.  If the cutoff is age 18 you risk overwhelming Dietitian staff who are already overworked, so start with age 65 and gather data.  [opinions are my own and not meant to represent the hospital or health system as a whole] (Submitted by: Northern Westchester Hospital)

  • The AHA disagrees with the MAP’s recommendation to refine and resubmit this measure and instead suggests that it not be supported. This measure has not completed field testing, and this measure has not been endorsed by the NQF committee on the basis that it fails the evidence criterion. (Submitted by: The American Hospital Association)

Standardized Transfusion Ratio for Dialysis Facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-305)
  • (Submitted by: Family Voices NJ)

  • MUC16-305—Standardized Transfusion Ratio for Dialysis Facilities (STrR; NQF 2979). KCP concurs with the MAP Hospital Workgroup recommendation of “Refine and Resubmit Prior to Rulemaking.” As the rationale for this decision detailed in the draft report and Excel document indicates, the measure does not adjust for the hospital- and physician-related transfusion practices that are out of dialysis facility control, and variability in hospital blood transfusion coding practices could inadvertently affect a dialysis facility's performance on this measure. However, we note that our impression from the Workgroup meeting was that a key rationale for the Workgroup’s recommendation on the measure was unacceptably low reliability in small facilities; this is not reflected in either the Draft Report or the Excel file of preliminary recommendations. Specifically, testing yielded IURs of 0.30-0.41 for small facilities for each of 2011, 2012, 2013, and 2014, indicating approximately 60-70% of a small facility’s score is due to random noise. KCP recommends that both documents be modified to include the rationale of low reliability depending on facility size to more fully reflect the rationale for the Workgroup’s recommendation. (Submitted by: Kidney Care Partners (KCP))

  • The AHA agrees that this measure does not meet the criteria for implementation, and thus agrees with the committee’s decision for this measure to be refined and resubmitted. This measure has some serious conceptual flaws considering that transfusions generally do not take place in ESRD facilities, so implementing this measure as it is would hold dialysis facilities accountable for procedures they generally don’t do. Data supports the lack of reliability this measure would provide, as any variation across such small facilities could overwhelmingly be attributed to chance. While there was some disagreement about whether the cited validity score was truly too low to be indicative of validity, the ESRD subject matter experts in attendance at the MAP meeting voiced serious concerns about how the measure lacked consideration for patient heuristics and facility size. In addition to these conceptual concerns, there is a technical issue with how the metric defines transfusions. This particular measure as proposed has a more conservative definition that calls for specific ICD-10 procedure or value codes; this means that unless a certain code is used, even in the event of a transfusion, the metric would not count that event. There is no requirement to enter these particular ICD-10 codes in the claim upon a transfusion event, so this metric would likely result in significant underreporting, rending it useless as a quality measure. (Submitted by: The American Hospital Association)

Hemodialysis Vascular Access: Standardized Fistula Rate (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-308)
  • MUC16-308—Hemodialysis Vascular Access: Standardized Fistula Rate (NQF 2977). KCP concurs with the recommendation to support MUC16-308, but recommends the developer consider modifications to improve the measure prior to incorporation into the ESRD QIP portfolio of measures: o KCP believes the specifications are imprecise as to whether facilities would receive credit for patients using an AVF as the sole means of access, but who also have in place a graft or catheter that is no longer being used. A numerator that specifies the patient must be on maintenance hemodialysis “using an AVF with two needles and without a dialysis catheter present” would remove ambiguity. o KCP believes two additional vasculature risk variables would strengthen the risk model: a history of multiple prior accesses and the presence of a cardiac device. (Submitted by: Kidney Care Partners (KCP))

Hemodialysis Vascular Access: Long-term Catheter Rate (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC16-309)
  • MUC16-309—Hemodialysis Vascular Access: Long-Term Catheter Rate (NQF 2978). KCP concurs with the recommendation to support MUC16-309. (Submitted by: Kidney Care Partners (KCP))

Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-312)
  • (Submitted by: American Academy of Otolaryngology - Head and Neck Surgery)

  • (Submitted by: Family Voices NJ)

Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-314)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. If the information in question is not valuable, this measure is evaluating little more than whether or not a packet of paper is received from the previous provider. (Submitted by: Adventist Health System)

  • (Submitted by: American Institutes for Research)

Safety Concern Screening and Follow-Up for Patients with Dementia (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-317)
  • Thank you for your conditional support of the Safety Concern Screening and Follow-Up for Patients with Dementia measure submitted by the American Academy of Neurology (AAN) and American Psychiatric Association (APA). We note the measure has been attributed to the American Psychological Association, and hope this error can be corrected.  The AAN and APA believe this measure will improve outcomes and make care safer for patients with dementia providing meaningful quality improvement data for providers. (Submitted by: American Academy of Neurology)

  • Overall, AAPM&R is in favor of this general measure and believe the three month follow up time is appropriate. (Submitted by: American Academy of Physical Medicine and Rehabilitation)

Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-319)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. If the information in question is not valuable, this measure is evaluating little more than whether or not a packet of paper is received from the previous provider. (Submitted by: Adventist Health System)

  • AMRPA agrees with the Workgroup’s recommendation that the measure be refined and resubmitted to NQF prior to further rulemaking activity. We have discussed similar issues in our comments submitted in response to NQF’s Measures Under Consideration (MUC) list in December 2016. Furthermore, AMRPA does not support the use of this measure as a quality measure. A quality metric generally presumes an outcome or result on which the measured provider’s behavior or actions could affect. That is not the case for this proposed measure which fundamentally assesses the behavior of an upstream entity – namely, did they transfer information to the receiving PAC provider. Hence, we recommend that the discussion about the measure be reframed so it is classified instead as a benchmarking and data collection effort, similar to CMS’s proposed assessment questions regarding the Route of Health Information Transfer. Essentially, this measure asks the receiving PAC provider: a) Did you receive any information and, if so, then b) Did you receive it in the stated categories? In its proposed use as a quality measure utilizing a numerator and denominator, this metric implies that a higher percentage equates to better performance. However, measuring receipt of information on admission as a percentage will measure only referring entities’ behavior, not the IRFs’, and IRFs should not be penalized or otherwise held accountable for the behavior of the referring entity. AMRPA also shares the MAP’s concern that only one of the eleven information categories need to be entered for the measure’s purposes. According to the proposed specifications, if one of the eleven categories of information is transferred, the PAC provider would check that category in the assessment form and the measure numerator is considered fulfilled. However, doing so begs the question of whether PAC providers will just check one in order to save time, regardless of how many types of information are received. If so, then there would be no benefit to the provider in checking more than one category. Again, the intent of this measure is more appropriate for data collection and benchmarking purposes, and not for quality and performance measurement purposes. (Submitted by: American Medical Rehabilitation Provider Rehabilitation Association )

  • ARN agrees that the measures' information is important, but partially redundant as there are existing regulations which already mandate the transfer of health information between settings. Patient and family engagement in care decisions is essential to improving quality of care and we agree with the types of information included in the measure, but believe that it could be strengthened by the inclusion of additional information. (Submitted by: Association of Rehabilitation Nurses)

  • (Submitted by: Family Voices NJ)

  • HealthSouth agrees with the MAP preliminary vote of refine and resubmit prior to rulemaking.  The IMPACT Act was passed to create standardized and interoperable measures. The lack of standardization across settings, particularly with the denominator of this measure, is a significant concern.  IRFs will capture Medicare A and C data, SNFs Medicare A only, LTCHs all patients, and HH will capture Medicare A and C and Medicaid.  These populations are significantly different from one another and in order to create standardized data, the measure should report on a common denominator across all settings: in this instance, Medicare A only.  This point was discussed at the MAP PAC/LTC committee meeting, but CMS offered no explanation for the rationale behind these discrepancies, choosing instead to only respond to public comments on other aspects of the measure.  We value the opportunity to interface with CMS at the MAP workgroup level, but hope there is some actual clinical or measurement rationale for this noticeable discrepancy.  MAP/LTC committee members also stressed the use of data already collected and transmitted to CMS where possible to reduce unnecessary burden and duplication. Additionally, as discussed at the MAP PAC/LTC committee meeting, providers across all post-acute care settings should not be held accountable for information received from upstream providers as a measure of quality. Certainly post-acute care providers should make a reasonable effort to “obtain” the necessary information to treat the patient, but may not receive the information, despite reasonable best efforts.  The word obtain is important – the Technical Expert Panel for this measure recommended the specifications replace the term “receive” with “obtain” since the information transfer depends on the receiving entity and the upstream transferring entity.  Since there is no corresponding measure in acute care that holds acute providers accountable for initiating the transfer of health information to PAC providers, it creates a “contingency gap” in the measure’s design from the PAC side. General Comment: Due to technical difficulties, public comments were not taken by phone regarding the IRF QRP measures.  There was no consideration to open public comment at a later time once the technical difficulties were resolved. (Submitted by: HealthSouth)

Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-321)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. If the information in question is not valuable, this measure is evaluating little more than whether or not a packet of paper is received from the previous provider. (Submitted by: Adventist Health System)

  • (Submitted by: Family Voices NJ)

Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Skilled Nursing Facility Quality Reporting Program; MUC ID: MUC16-323)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. However, from the perspective of the discharging facility the more important question is: “Did someone at the admitting facility read it?” (Submitted by: Adventist Health System)

  • (Submitted by: American Academy of Hospice and Palliative Medicine)

  • ARN agrees that the measures' information is important but partially redundant. (Submitted by: Association of Rehabilitation Nurses)

  • (Submitted by: Family Voices NJ)

Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: MUC16-325)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. However, from the perspective of the discharging facility the more important question is: “Did someone at the admitting facility read it?” (Submitted by: Adventist Health System)

  • AMRPA agrees with the MAP’s recommendation that the measure be refined and resubmitted to NQF prior to further rulemaking activity. AMRPA believes this proposed measure lends itself more readily to being characterized as a quality measure as the information was in the control of the PAC provider. However, similar to the Transfer of Information at Admission measure, various information categories proposed for the discharge measure are also redundant and burdensome. In reality, IRFs generally provide this information at discharge to the next provider or the patient/caregivers. However, to pull it from the patient record and then cross-reference it by the measure’s categorical definitions may be an extra burdensome task. We are foremost concerned with the heavy obligation this measure would create for provider. Items such as “Administrative information” should be reexamined and narrowed, as they are redundant and therefore increase reporting costs and obligations unnecessarily. (Submitted by: American Medical Rehabilitation Provider Rehabilitation Association )

  • (Submitted by: Family Voices NJ)

  • HealthSouth agrees with the MAP preliminary vote of refine and resubmit prior to rulemaking.  In addition to incomplete development, the IMPACT Act was passed to create standardized and interoperable measures. The lack of standardization across settings, particularly with the denominator of this measure, is a significant concern.  IRFs will capture Medicare A and C data, SNFs Medicare A only, LTCHs all patients, and HH will capture Medicare A and C and Medicaid.  These populations are significantly different from one another and in order to create standardized data, the measure should report the common denominator among all settings: in this instance, Medicare A only.  This was discussed at the MAP PAC/LTC committee meeting, but CMS offered no explanation for the rationale behind these discrepancies, choosing instead to only respond to public comments on other aspects of the measure. We value the opportunity to interface with CMS at the MAP workgroup level, but hope there is some actual clinical or measurement rationale for this noticeable discrepancy.  MAP/LTC committee members also stressed the use of data already collected and transmitted to CMS where possible to reduce unnecessary burden and duplication. General Comment: Due to technical difficulties, public comments were not taken by phone regarding the IRF QRP measures.  There was no consideration to open public comment at a later time once the technical difficulties were resolved. (Submitted by: HealthSouth)

Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: MUC16-327)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. However, from the perspective of the discharging facility the more important question is: “Did someone at the admitting facility read it?” We also wish to point out that this measure has not been endorsed and reiterate our recommendation that MAP refrain from supporting any measure that has not achieved NQF endorsement. (Submitted by: Adventist Health System)

  • ARN agrees that the measures' information is important but partially redundant. ARN agrees with the information included in the measure, but believes that the measure could be strengthened by the inclusion of additional information. (Submitted by: Association of Rehabilitation Nurses)

  • (Submitted by: Family Voices NJ)

Appropriate Documentation of a Malnutrition Diagnosis (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-344)
  • Adventist Health System supports MAP’s preliminary recommendation and rationale. Moreover, we believe the Workgroup’s discussion highlights the importance of achieving NQF endorsement prior to implementation in federal programs. We believe NQF endorsement is the best way to ensure that measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, consistent across types of health care providers, and responsive to variations in patient characteristics. Completing the NQF endorsement process can help address and resolve the important issue regarding evidence that the Workgroup raised. (Submitted by: Adventist Health System)

Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Program: Home Health Quality Reporting Program; MUC ID: MUC16-347)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. If the information in question is not valuable, this measure is evaluating little more than whether or not a packet of paper is received from the previous provider. (Submitted by: Adventist Health System)

  • ARN agrees that the measures' information is important but partially redundant. ARN believes that the measure could be strengthened by the inclusion of additional information. (Submitted by: Association of Rehabilitation Nurses)

Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Program: Home Health Quality Reporting Program; MUC ID: MUC16-357)
  • Adventist Health System supports MAP’s preliminary decision and rationale. We are concerned that this measure may be subjective and that it is structured in a way that leads to an assessment of the quantity of information but not the quality of that information. We believe that the goal of this measure is to ensure that admitting facilities receive valuable actionable information about patients’ health and care preferences. However, from the perspective of the discharging facility the more important question is: “Did someone at the admitting facility read it?” (Submitted by: Adventist Health System)

  • ARN agrees that the measures' information is important but partially redundant. ARN believes that the measure could be strengthened by the inclusion of additional information. (Submitted by: Association of Rehabilitation Nurses)

Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC16-372)
  • We commend the Hospital Workgroup for recognizing that there is a malnutrition gap and that the eCQM measure set can bring value to improving quality of care for hospitalized older adults.  After the initial MAP review the Health and Well-being Standing Committee recommended endorsement for NQF #3089 (MUC16-372) Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment.  Based upon this new information we request the MAP to consider changing the recommendation for MUC16-372 to “conditional support” for inclusion pending final approval for NQF endorsement.  We believe a “conditional support” for MUC16-372 is aligned with the workgroup initial recommendations, is an important first step to fill the identified gap and improve patient quality care, and provides a near-term NQF-endorsed and MAP recommended measure for consideration in the IQR.   Up to 39% of hospitalized older adults are malnourished, leading to increased mortality, longer lengths of stay, higher readmissions rates, and greater complications. (Kaiser MJ et al. J Am Geriatr Soc. 2010; Pereira GF et al, Ann Emerg Med. 2015; Weiss et al 2016).  As a result the impact of malnutrition on patients and the healthcare system is significant with an economic burden estimated at $51.3 billion for older adults (Snider et al 2014).    Early nutrition intervention has been demonstrated to help decrease preventable readmissions, complications, length of hospital stay, and reduce mortality.  A recent prospective, randomized, double-blind, placebo-controlled, multicenter study of 652 hospitalized malnourished older adults found a significant reduction in post-discharge outcomes of 30, 60, and 90-day mortality (>50% reduction) and improvement in nutritional status (handgrip strength and weight gain) when patients were assessed and diagnosed using the Subjective Global Assessment and then received nutrition intervention with a specialized oral nutritional supplement within 72 hours.  No effects of the intervention were observed for the primary composite endpoint of non-elective readmission or death at 90 days (Deutz et al, Clinical Nutrition 35 2016).  Similarly a nutrition-focused quality improvement program with 1269 hospitalized adults demonstrated that optimal nutrition care that included accelerated nutrition intervention for at-risk patients, patient/caregiver education upon discharge and sustained nutrition support resulted in a 27 percent reduction in 30-day readmission rates and a decrease in average hospital length of stay by almost two days for malnourished patients (Sriram et al, JPEN Online December 6, 2016).   The development and documentation of the nutrition care plan is driven by the nutrition assessment, is the communication mechanism to all clinicians who interact with the patient, and initiates recommended nutrition interventions in the acute setting and supports care transitions and appropriate nutrition support in post-acute care and at home. (Submitted by: Abbott)

  • Development and documentation of the nutrition care plan is driven by the nutrition assessment and is required to record vital patient care information, including nutrition status, diagnosis, monitoring recommendations, and interventions. The nutrition assessment-based care plan is the communication mechanism to all clinicians who interact with the patient. Moreover, it reflects the care provided in the hospital setting and becomes the information communicated to the next-in-line provider. As such, documentation of the care plan in a standardized, structured, and consistent manner is a critical activity for care provision in the acute setting and to support care transitions and appropriate nutrition support beyond the hospital. The impact of malnutrition on patients and the healthcare system is significant. Recent national data show that malnourished patients are half as likely to be discharged home from a hospital, 4.9 times more likely to die in the hospital, have up to 100% longer lengths of stay, and cost twice the average inpatient stay. Thus higher healthcare costs from disease-related malnutrition in the U.S. are $157 billion, with $51.3 billion attributed to those age 65 years and older. Furthermore, 30-day readmission rates for malnourished patients in 2013 averaged 23 per 100, compared with 14.9 per 100 without malnutrition. Costs were also 26% higher for readmissions involving patients with malnutrition than average readmissions without malnutrition. Results of testing for this measure reflect the importance of appropriate and consistent documentation of nutrition care plans, highlighting the high variability in care plan documentation among hospitals and clinicians. Currently, there is a large performance gap across institutions’ adherence with nutrition care process recommendations and documentation of the findings of each step in a standardized fashion. In the literature, this phenomenon is evident in highly underreported rates of malnutrition using claims-based data sources, in conflict with dozens of studies showing significantly higher rates of malnutrition. Documenting recommendations for care in a care plan is recommended by numerous guidelines to deliver standard, consistent, high quality care. , , Hospitals that implement appropriate nutrition care processes should have standardized terminology for documenting assessment results as well as the components of a nutrition care plan. The testing data demonstrate reliability and validity of the measure’s data elements and were calculated using approved methods indicated in NQF’s Measure Evaluation Criteria and Guidance. The statistics reported on the critical data elements reflect at least 90% agreement on average across the testing sites, as well as kappa statistics reflecting substantial agreement and some almost perfect agreement. This measure is important to address a major gap in care that can result in preventable adverse outcomes for hospitalized patients. We ask the Committee to acknowledge the case for validity presented by the developer and move towards consensus endorsement of this measure. (Submitted by: Academy of Nutrition and Dietetics )

  • The Academy and Avalere request the Coordinating Committee reconsider the initial recommendation by the MAP Hospital Workgroup to refine and resubmit MUC16-372 and consider recommending conditional support pending NQF endorsement. MUC16-372 was recently recommended for endorsement by the Health and Well-being Standing Committee, which indicates that the measure is evidence-based, reliable, valid and feasible for use. This measure is important to address a major gap in care that can result in preventable adverse outcomes for hospitalized patients. Documenting recommendations for care in a care plan is recommended by numerous guidelines to help standardize care to improve quality and consistency of care patients receive.[1,2,3] Development and documentation of the nutrition care plan, based on results of the nutrition assessment, is an important step to capture key aspects of the patient’s care, including nutritional status, diagnosis, monitoring and follow up recommendations, and interventions recommended. The care plan relies on the findings of the nutrition assessment and is the mechanism by which care practices are communicated to all clinicians who interact with the patient. Moreover, this care plan reflects the care provided in the hospital setting and forms the basis for information communicated to the next-in-line provider. As such, documentation of the care plan in a standardized, structured, and consistent manner is a critical activity not only for care provision in the acute setting, but to support care transitions and appropriate nutrition support beyond the hospital. In fact, the Joint Commission acknowledges the value of hospital’s establishing defined criteria for identifying when nutritional plans are developed for patients by including this practice as part of its Provision of Care standards (PC.01.02.01, EP 3).[4] Malnutrition presents a significant risk to the health outcomes of patients, with up to 39% of hospitalized older adult patients being malnourished.[5,6] Up to 31% of these malnourished patients and 38% of well-nourished patients experience nutritional decline during their hospital stay.[7] Many patients continue to lose weight after discharge[8], and patients with weight loss are at increased risk for readmission.[9] Moreover, patients with malnutrition have up to 100% longer lengths of stay, twice as costly episodes of care, are half as likely to be discharged home and are 4.9 times more likely to result in in-hospital death than other patients with non-maternal/non-neonatal stays.[10] References: [1] Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2016; http://dx.doi.org/10.1016/j.clnu.2016.09.004. [2] British Association for Parenteral and Enteral Nutrition. Malnutrition Matters, A Toolkit for Clinical Commissioning Groups and providers in England. Published 2012. Retrieved from: http://www.bapen.org.uk/pdfs/bapen_pubs/bapen-toolkit-for-commissioners-and-providers.pdf. [3] Academy of Nutrition & Dietetics. CI: Nutrition Assessment of Critically Ill Adults 2012. Academy of Nutrition & Dietetics Evidence Analysis Library. Published 2012. Retrieved from: http://www.andeal.org/topic.cfm?menu=4800. [4] Standards information for hospitals. The Joint Commission. https://www.jointcommission.org/accreditation/hap_standards_information.aspx. Accessed October 11, 2016. [5] Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-8. [6] Pereira GF, Bulik CM, Weaver MA, Holland WC, Platts-mills TF. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med. 2015;65(1):85-91. [7] Braunschweig C, et al. J Am Diet Assoc. 2000;100 (11):1316-1322. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. [8] Beattie AH, et al: A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut. 2000;46:813-818. [9] Allaudeen N, et al: redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6:54-60. [10] Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.pdf. (Submitted by: Academy of Nutrition and Dietetics & Avalere Health)

  • We commend the Hospital Workgroup acknowledgement in the report that there is malnutrition gap and that the proposed malnutrition eCQM suite could bring value to improving quality of care for patients. We urge the Coordinating Committee to consider changing the recommendation for MUC16-372 to “conditional support” for inclusion in the HIQR, pending NQF endorsement. After the MAP Hospital Workgroup discussions, the Health and Well-being Standing Committee advanced NQF #3089 (MUC16-372) for endorsement. A conditional support recommendation for MUC16-372 is in alignment with the workgroup recommendations and will provide a pathway to fill the gap and help improve quality patient care with an NQF endorsed measure until a future malnutrition composite measure, as recommended by the workgroup, is available. Adoption of this nutrition care plan measure in the HIQR measure set will help improve quality and outcomes for patients in the acute setting and support care transitions and appropriate nutrition support beyond the hospital. Development and implementation of the Nutrition Care Plan is particularly important as a recent AHRQ HCUP analysis found that malnourished hospitalized adults are older, half as likely to be discharged to home, have hospital 30-day readmissions that are 54% higher than non-malnourished patients with an average cost of readmission of $17,000 per patient, and creates an estimated $42 billion burden to the healthcare system.¹,² The nutrition assessment-based care plan initiates the intervention, is the communication mechanism to all clinicians who interact with the patient in the hospital and becomes the information communicated to the next-in-line provider outside the hospital upon discharge planning. ¹Weiss AJ et al. AHRQ HCUP Statistical Brief #210. September 2016. ²Fingar KR et al. AHRQ HCUP Statistical Brief #218. December 2016. (Submitted by: AdvaMed)

  • Adventist Health System supports MAP’s preliminary recommendation and rationale. We commend the Workgroup for emphasizing the need to ensure it is valid. We believe NQF endorsement is the best way to ensure that measures are indeed valid. In addition, we view NQF endorsement as the preeminent standard by which to confirm measures are evidence-based, reliable, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics and consistent across types of health care providers. For these reasons, we believe it is important that measures be evaluated and endorsed by NQF prior to implementation in federal programs. (Submitted by: Adventist Health System)

  • We request that the Coordinating Committee reconsider the recommendation of “refine and resubmit” for MUC16-372. After the hospital workgroup review, MUC16-372 was recommended for endorsement by the Health and Well-being Standing Committee, which indicates that the measure is evidence-based, reliable, valid and feasible for use. We commend the Workgroup’s recognition in the report that the impact of malnutrition on patients and the healthcare system is significant with conditional support of a malnutrition measure. Recent national data show that malnourished patients are five times more likely to die in the hospital, have up to 100% longer lengths of stay, and cost twice the average inpatient stay[1]. Thus healthcare costs related to disease-related malnutrition in the U.S. are estimated to be $51.3 billion for those age 65 years and older[2]. Furthermore, 30-day readmission rates for malnourished patients in 2013 averaged 23 per 100, compared with 14.9 per 100 without malnutrition. Costs were also 26% higher for readmissions involving patients with malnutrition than average readmissions without malnutrition.[3] Development and documentation of the nutrition care plan is driven by the nutrition assessment and is required to record vital patient care information, including nutrition status, diagnosis, monitoring recommendations, and interventions. Moreover, the nutrition care plan is the communication mechanism to all clinicians who interact with the patient in the hospital setting and becomes the information communicated to the next-in-line provider outside the hospital. This is particularly important as malnourished patients are more likely to be discharged to another facility[4] or require ongoing healthcare services after being discharged from the hospital, compared to patients who are not at risk for malnutrition.[5] Community-based services may include but are not limited to congregate and home-delivered meals, education and counseling, and an array of other supportive and health services. As such, documentation of the care plan in a standardized, structured, and consistent manner is a critical activity for care provision in the acute setting and to support care transitions to post-acute care or home. 1 Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD. 2 Snider J, et al: Economic burden of community-based disease-associated malnutrition in the United States. JPEN J Parenteral Enteral Nutr. 2014;38:55-165. 3 Fingar KR, Weiss AJ, Barrett ML, Elixhauser A, Steiner CA, Guenter P & Brown MH. All-Cause Readmissions Following Hospital Stays for Patients With Malnutrition, 2013. HCUP Statistical Brief #218. December 2016. Agency for Healthcare Research and Quality, Rockville, MD. 4 Chima CS, et al. Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service. J Am Diet Assoc. 1997; 97(9): 975-8. 5 Zdrowski CD, et al. Malnutrition in sub-acute care. Am J Clin Nutr. 2002; 75: 308-313. (Submitted by: Defeat Malnutrition Today)

  • (Submitted by: Healthcare Nutrition Council)

  • The AHA disagrees with the MAP’s recommendation to refine and resubmit this measure, as the measure relies upon information collected in measures that do not meet the evidence criterion of the NQF endorsement process (MUC16-294 and MUC16-296). Because of this, the AHA recommends that the committee does not support this measure. While nutrition care plans are associated with improved patient outcomes, this particular measure introduces even more data collection. This would alter the scope of practice, and with the previous two measures (which would be necessary to support this measure) would add 3 new metrics. In addition, this measure is specified as an eCQM; many questions remain on the feasibility and accuracy of these electronic measures, which must be addressed before additional measures move forward. While the AHA acknowledges that malnutrition can have serious deleterious effects on health, this measure is built upon the collection of information from the proposed measures on nutrition screenings and assessments; if those two measures have not met the evidence standard of the NQF endorsement process, it is unlikely that those necessary preliminary steps will yield useful and reliable data to inform this measure. (Submitted by: The American Hospital Association)

PRO utilization in in non-metastatic prostate cancer patients (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC16-393)
  • We urge the MAP to reconsider its preliminary decision for this measure, based on the following considerations: • The adoption of PROs as clinical care tools is well recognized as a significant but worthwhile undertaking. Adoption of the proposed structural measure presents minimal reporting burden and was proposed as a stepping stone to the adoption of PRO-PMs with two key goals: 1) allow facilities to gain early experience with longitudinal PROs as a standard of care; and, 2) allow CMS to gather data on the challenges of PRO adoption and longitudinal measurement in cancer. We believe that this information can inform future PRO-based measurement in other CMS programs, such as the IQR, OQR, and MIPS. The structural measure would be reported annually, with an estimated burden to respond to the 5-question survey of less than 2 hours per year. • This measure is patterned after the Hospital Survey on Patient Safety Culture measure (MUC # X3689, supported by the MAP in its MAP 2014-2015 Preliminary Recommendations and adopted by CMS for the IQR in the FY2016 IPPS Final Rule). In the FY2016 IPPS Final Rule (pg. 49672), CMS estimated a minimal burden for the Hospital Survey on Patient Safety Culture. • This measure is proposed for voluntary reporting and is not tied to payment. We believe that it is fully specified. The PRO domains are derived from validated PRO questionnaires and literature regarding quality of life and functional status outcomes that are relevant for prostate cancer. Additionally, we believe that testing could be conducted in real-time along with data collection. This is consistent with CMMI’s approach in the Comprehensive Care for Joint Replacement Model, where PROs are adopted for voluntary reporting in Years 1-3 of the program for purposes of developing validated PRO-PMs for subsequent program years. (Submitted by: Alliance of Dedicated Cancer Centers)

  • We respectfully request the MAP reconsider its decision on this measure, as it serves as a significant stepping stone toward the ultimate goal of reporting patient-reported outcomes data. We recommend there be flexibility in the tool used to encourage adoption of collection of patient-reported outcomes data. (Submitted by: Memorial Sloan Kettering Cancer Center)

  • We appreciate that this is a structural measure but would request reconsideration given the increasing importance of patient-reported outcomes to CMS and to value-based care. Moffitt Cancer Center and the ADCC are committed to embedding PRO metrics into our plans of care, as part of our true partnership with patients and shared decision-making. As a stepping stone, we believe that this measure serves a specific purpose to create the infrastructure necessary to lead to a PRO-PM for prostate cancer as well as creating the pathway for identifying and measuring PORs in other malignancies. Moffitt Cancer Center would request that MAP reconsider its preliminary recommendation and support MUC16-393. We support the addition of the four measures related to end of life care as well as the retirement of the designated treatment-specific measures. (Submitted by: Moffitt Cancer Center)

  • We are encouraged by the discussions related to appropriate use of interventions and measurement that facilitates patients making more informed choices. We are aligned in our desire to provide appropriate end of life care. We are advocating that the MAP reconsider its position on the Patient-reported Outcome tool utilization measure for prostate cancer. We completely agree that the goal should be patient-reported outcome measures. That said, we believe this structural measure would assess the near-term feasibility for institutions to implement a patient-reported outcome measure. The Hospital Workgroup raised concerns around administration burden and expressed a need for new approaches to capturing PROs. Given these discussions, we feel the first step is to prioritize the collection of PROs, which will drive innovations in the administration and collection space. (Submitted by: Seattle Cancer Care Alliance)

  • The AHA agrees with the committee’s recommendation of Do Not Support. The results of a well-designed, appropriately risk-adjusted PRO measure would be far more meaningful than this measure merely asking whether a provider used a PRO instrument or not. (Submitted by: The American Hospital Association)

  • The routine use of patient-reported outcomes (PRO) instruments as clinical care tools supports improved patient care, patient engagement, and, ultimately, our research mission.  Longitudinal collection and reporting of these functional status and quality-of-life outcomes aligns with institutional goals to deliver patient-centered, value-driven care.  To that end, we implemented the Epic electronic health record in 2016 with the functionality to automate PROs for use in clinical care and to aggregate responses for purposes of internal benchmarking and quality reporting.  We are actively working with our clinical care teams to integrate PROs within the clinical workflow to ensure a seamless patient experience and to minimize provider burden.  Additionally, we are working with other PCHs (together, the Alliance of Dedicated Cancer Centers or ADCC) to validate PRO-based performance measures (PRO-PM) for non-metastatic prostate cancer.  Outcomes, such as long-term preservation of continence and sexual function, assess the quality of life and functional status dimensions that are most important to patients diagnosed with localized prostate cancer.  Because the PRO-PMs are longitudinal in nature, several ADCC centers collaborated to define an interim structural measure with the following goals:  1) Enable facilities to gain early experience with longitudinal PROs as a standard of care; and, 2) Allow the Centers for Medicare & Medicaid Services (CMS) to gather data on the challenges of PRO adoption and longitudinal measurement in cancer.  The ADCC (with MD Anderson as the measure steward) submitted the PRO Utilization in Non-Metastatic Prostate Cancer Patients measure (MUC16-393) to the Measures Under Consideration (MUC) List in 2016.  This measure was reviewed by the MAP Hospital Workgroup in December, and thoughtful discussion ensued.  Ultimately, the Workgroup did not support the measure for Rulemaking, questioning the value of a structure measure to patients and consumers.  We urge the MAP to reconsider this position and to support this measure for Rulemaking.  We believe that this measure brings value to the PCHQR program by demonstrating the PCHs’ commitment to patient-centered outcome measurement in the form of PROs and by creating a national venue to share real-world experience with PRO-PM measure development, which can then inform PRO-PM measure development efforts in cancer and other conditions.  Additionally, we offer the following considerations:  • The adoption of PROs as a standard of care is a substantial but well-supported undertaking.  We fully support the adoption of PRO-PMs for the PCHQR program.  However, the longitudinal nature of these outcomes—and associated measure testing—has delayed fully tested PRO-PMs in this population.  An interim structure measure can establish a measurement foundation to accelerate the adoption of PROs as clinical care tools, preparing providers and hospitals for the transition to PRO-PMs.  • We submitted this measure for voluntary reporting with support from other PCHs; it is not tied to payment.  The measure is fully specified and derives from validated PRO instruments and literature regarding quality of life and functional status outcomes that are relevant for prostate cancer.  Although the measure has not been through formal reliability and validity testing, such testing could occur in real-time along with data collection.  This follows the approach adopted by the Centers for Medicare & Medicaid Innovation (CMMI) for the Comprehensive Care for Joint Replacement Model.  In Years 1-3 of this program, PROs will be voluntarily reported in Years 1-3 of the program to provide the necessary dataset to validate PRO-PMs in subsequent program years.  This voluntary reporting serves as a stepping-stone to mandatory PROs within the program. • This measure is patterned after the Hospital Survey on Patient Safety Culture measure (MUC # X3689).  Of note, the MAP supported this non-endorsed measure in the MAP 2014-2015 Preliminary Recommendations, noting that “. . . participation in a patient safety culture survey is an important element to building a system of quality improvement within health care facilities.”   On this basis, CMS adopted this measure for the Inpatient Quality Reporting (IQR) program in the FY2016 IPPS Final Rule.  Similarly, by gaining early experience with PROs in the clinical setting, PCHs can build the infrastructure for meaningful patient-centered outcomes, as encouraged by this measure.  This early experience will likewise benefit CMS, informing future efforts to incorporate condition-specific PRO-PMs and longitudinal outcomes within public reporting programs. (Submitted by: The University of Texas MD Anderson Cancer Center)

Appropriate Use Criteria - Cardiac Electrophysiology (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-398)
  • We support the MAP’s recommendation that this measure be refined and resubmitted. We agree with the concerns expressed by the MAP that insufficient detail has been provided to fully evaluate this measure. The AHA partnered on development of the 2013 ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR Appropriate Use Criteria (AUC) for ICDs and CRT, which is listed in the measure rationale, and we support use of the AUC to improve practice. However, we do not have enough information about this measure to evaluate whether it is fully aligned with the AUC or if it is likely to be a feasible and meaningful measure. Some of the questions and concerns we have regarding this measure are discussed below. It appears that the measure may be limited to appropriate use of ICDs and CRT, but this is not explicitly stated. The rationale also refers to appropriate imaging. The numerator is defined only as the “number of reports meeting AUC.” However, it’s unclear whether only procedures rated “Appropriate” (median Score 7 to 9) would be included in the numerator or if procedures rated “May Be Appropriate” (median Score 4 to 6) would also be included. It’s also not possible to determine from the information provided if all 369 of the clinical scenarios included in the AUC document would have to be mapped or how patients whose clinical situation is not included among the scenarios are handled in the measure. The AUC document suggests that specific clinical situations not addressed in the scenarios evaluated in the document should be considered in their unique contexts, however, there are no exclusions listed for the measure. We strongly urge the MAP and CMS to defer any further consideration of this measure until adequate information is available to evaluate it and the measure has been fully tested. (Submitted by: American Heart Association)

  • AUC is a complex initiative as there are many  medical professionals and other testing that is needed to ascertain that the patient meets the criteria  to have the EP procedure. The EP specialist may not have access to any information other than the referral to perform the procedure - which appears to be appropriate. It is critical that other tests are accurate and that clinical data is documented appropriately beginning with the patient's history and along the continuum of care  such as blood work, echocardiography and nuclear studies and other tests the patient receives leading to the conclusion that the patient meets the clinical criteria warranting the procedure. The outcome (performing the procedure) may be different if the EP specialist had all of the clinical data at their disposal. All clinicians involved in the care of this patient need to document appropriateness of care along the continuum to ensure test appropriateness. Appropriate testing cannot be evaluated in a vacuum or as an isolated event as there are many components,medical professionals and tests involved that are crucial in the decision making process. (Submitted by: IAC)

Identification of Opioid Use Disorder (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC16-428)
  • There is concern that this measure may lead to unnecessary or over testing. If patients admit to opioid use, must they still be screened for opioids? The reliability of PDMP systems may vary from state to state. Consideration should be given to account for this variation. (Submitted by: Johns Hopkins Armstrong Institute for Patient Safety and Quality)

  • As reported in the draft report, the workgroup areas for future development (ED patients not admitted and access).  We feel strongly these are not areas over which hospitals have domain and they should not be included.  We also support the recommendation that measures that are not NQF endorsed should be removed from the program. The workgroup also recommended a discharge planning measure. A very comprehensive discharge measure was added to the program beginning January 2017 so we feel no further work is necessary. We strongly support the recommendation that the measure be fully tested and that it be submitted to NQF for review.  We also strongly agree with the comment made in the workgroup discussion that there is a high number of drug and alcohol measures in the program. We do not think this measure would bring value to the program. (Submitted by: National Association of Psychiatric Health Systems)

  • The AHA agrees that this measure needs further refinement before it is included in the IPF quality reporting program because of significant technical and conceptual concerns. Technically, the measure relies on documentation of opioid abuse disorder as “mild, moderate, or severe,” which appear to be more terms of art than science. Without further guidance on how to clinically delineate these categories, it seems inappropriate to require reporting. Conceptually, the measure will likely not provide any additional value to what existing IPF intake processes find. Requiring IPF providers to report that they have made this documentation is unlikely to show whether the IPF is improving care and outcomes in a meaningful way. (Submitted by: The American Hospital Association)

Appendix D: Instructions and Help

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

Navigating the Discussion Guide

  • 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