| Day 1 | |
| 8:00 am | Breakfast |
| 8:30 am | Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach |
| Frank Opelka, Workgroup Chair; Ron Walters, Workgroup Co-Chair;
Taroon Amin, Senior Director, NQF | |
| 8:45 am | Measures Under Consideration for Hospital Outpatient Quality Reporting Program |
| OQR Calendar 1: Support | |
| Programs under consideration: Hospital
Outpatient Quality Reporting Program | |
| Lead discussant(s): Jamie Brooks Robertson, David Engler | |
| |
| OQR Calendar 2: Conditional support pending NQF endorsement | |
| Programs under consideration: Hospital
Outpatient Quality Reporting Program | |
| Lead discussant(s): Daniel Pollock, Richard Bankowitz | |
| |
| OQR Calendar 3: Conditional support pending the development of the single composite measure | |
| Programs under consideration: Hospital
Outpatient Quality Reporting Program | |
| Lead discussant(s): Kelly Trautner, Michael Phelan | |
| |
| OQR Calendar 4 (Under Development): Encouraged for continued development | |
| Programs under consideration: Hospital
Outpatient Quality Reporting Program | |
| Lead discussant(s): Amanda Stefancyk Oberlies, Jack Fowler | |
| |
| 9:45 am | Measures Under Consideration for Ambulatory Surgical Center Quality Reporting |
| ASCQR Calendar 1: Support | |
| Programs under consideration: Ambulatory
Surgical Centers Quality Reporting Program | |
| Lead discussant(s): R. Sean Morrison, Helen Haskell | |
| |
| ASCQR Calendar 2: Conditional support pending the completion of reliability testing and NQF endorsement | |
| Programs under consideration: Ambulatory
Surgical Centers Quality Reporting Program | |
| Lead discussant(s): Donna Slosburg, Cristie Travis | |
| |
| ASCQR Calendar 3: Do Not Support | |
| Programs under consideration: Ambulatory
Surgical Centers Quality Reporting Program | |
| Lead discussant(s): Mitchell Levy, Martin Hatlie | |
| |
| ASCQR Calendar 4: (Under Development) Encouraged for continued development | |
| Programs under consideration: Ambulatory
Surgical Centers Quality Reporting Program | |
| Lead discussant(s): Amanda Stefancyk Oberlies, Jack Fowler | |
| |
| 10:45 am | Opportunity for Public Comment |
| 11:00 am | Break |
| 11:15 pm | Measures Under Consideration for Medicare Shared Savings Program |
| MSSP Calendar 1: Support | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Michael Phelan, Jamie Brooks Robertson | |
| |
| MSSP Calendar 2: Conditional support pending resolution of data concerns | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Daniel Pollock, Mitchell Levy | |
| |
| MSSP Calendar 3: Conditional Support pending NQF review and endorsement | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Richard Bankowitz, Helen Haskell | |
| |
| MSSP Calendar 4: Conditional Support pending resubmission to NQF for endorsement review | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Shekar Mehta, Dana Alexander | |
| |
| MSSP Calendar 5: Do Not Support | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Karen Fields, Andrea Benin | |
| |
| MSSP Calendar 6: (Under Development) Encouraged for continued development | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Wei Ying, David Engler | |
| |
| MSSP Calendar 7: (Under Development) Do not encourage further consideration | |
| Programs under consideration: Medicare
Shared Savings Program | |
| Lead discussant(s): Sean Morrison, Amanda Stefancyk Oberlies | |
| |
| 12:30 pm | Lunch |
| 1:30 pm | Measures Under Consideration for Hospital-Acquired Condition (HAC) Reduction Program |
| HAC Calendar 1: Support | |
| Programs under consideration: Hospital-Acquired
Condition (HAC) Reduction Program | |
| Lead discussant(s): Helen Haskell, Mitchell Levy | |
| |
| 2:00 pm | Measures Under Consideration for Inpatient Psychiatric Facility Quality Reporting |
| IPFQR Calendar 1: Support | |
| Programs under consideration: Inpatient
Psychiatric Facilities Quality Reporting Program | |
| Lead discussant(s): Wei Ying, Frank Opelka, Dolores L. Mitchell | |
| |
| IPFQR Calendar 2: Conditional Support upon harmonization with HBIPS-7 | |
| Programs under consideration: Inpatient
Psychiatric Facilities Quality Reporting Program | |
| Lead discussant(s): Karen Fields, Cristie Upshaw Travis | |
| |
| 2:35 pm | Break |
| 2:45 pm | Measures Under Consideration for Medicare and Medicaid EHR Incentive Program for Hospitals and CAHs (Meaningful Use) |
| MU Calendar 1: (Under Development) Encouraged for continued development | |
| Programs under consideration: Medicare
and Medicaid EHR Incentive Program for Hospitals and Critical Access
Hospitals (CAHs) | |
| Lead discussant(s): Ronald S. Walters, Martin Hatlie, Shekhar Mehta | |
| |
| 3:20 pm | Opportunity for Public Comment |
| 3:35 pm | Summary of Day |
| 3:50 pm | Adjourn |
| Day 2 | |
| 8:00 am | Breakfast |
| 8:30 am | Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach |
| Frank Opelka, Workgroup Chair; Ron Walters, Workgroup Co-Chair; Taroon
Amin, Senior Director, NQF | |
| 8:45 am | Measures Under Consideration for Hospital Inpatient Quality Reporting |
| IQR Calendar 1: Support | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Brock Slabach, Helen Haskell | |
| |
| IQR Calendar 2: Conditional support pending NQF review of the testing data in a Medicare population and resolution of parsimony concerns with measures currently in the IQR program | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Dolores L. Mitchell, Jamie Brooks Robertson, Shelley Fuld Nasso | |
| |
| _ | IQR Calendar 3: Conditional support. This measure should be quickly replaced with a measure assessing results of a survey of a culture of patient safety |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Shekhar Mehta, Cristie Travis | |
| |
| IQR Calendar 4: Conditional Support pending demonstration of applicability at the facility level and resolution of the duplicative nature of this measure with the falls and trauma component of PSI-90 | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Martin Hatlie, Richard Bankowitz | |
| |
| IQR Calendar 5: Conditional Support pending NQF review and endorsement | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): David Engler, Karen Fields, Ronald Walters | |
| |
| IQR Calendar 6: Do Not Support | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Nancy Foster, Dana Alexander | |
| |
| IQR Calendar 7: (Under Development) Encouraged for continued development | |
| Programs under consideration: Inpatient
Quality Reporting Program | |
| Lead discussant(s): Richard Bankowitz, Jack Fowler, Jr., Andrea Benin | |
| |
| 10:35 | Public Comment on IQR Consent Calendars |
| 10:45 am | Break |
| 11:00 am | Measures Under Consideration for Hospital Value-based Purchasing (VBP) Program |
| VBP Calendar 1: Support | |
| Programs under consideration: | |
| Lead discussant(s): Michael P. Phelan, Mitchell Levy | |
| |
| 12:20 pm | Public Comment on VBP Consent Calendars |
| 12:30 pm | Lunch |
| 1:30 pm | Measures Under Consideration for PPS-Exempt Cancer Hospital Quality Reporting Program |
| PCHQR Calendar 1: Support | |
| Programs under consideration: PPS-Exempt
Cancer Hospital Quality Reporting Program | |
| Lead discussant(s): Shelly Nasso R. Sean Morrison Louise Y. Probst | |
| |
| PCHQR Calendar 2: (Under Development) Encourage continued development | |
| Programs under consideration: PPS-Exempt
Cancer Hospital Quality Reporting Program | |
| Lead discussant(s): David Engler, Cristie Upshaw Travis, Shekhar Mehta | |
| |
| 2:20 | Public Comment on PCHQR Consent Calendars |
| 2:30 pm | Measures Under Consideration for Hospital Readmission Reduction Program |
| HRRP Calendar 1: Support | |
| Programs under consideration: Hospital
Readmission Reduction Program | |
| Lead discussant(s): Kelly Trautner David Engler | |
| |
| 3:00pm | Public Comment on HRRP Consent Calendars |
| 3:15 pm | Feedback on Process Improvements |
| 3:45 pm | Summary of Day |
| 4:00 pm | Adjourn |
| 30 Day Unplanned Readmissions for Cancer Patients for program(s): PCHQR (MUC ID: X3629) |
NQF Number (if applicable):
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure is still under development and not yet ready to be included in the PPS-exempt Cancer HQR Program. Upon submission and recommendation for NQF-endorsement, this measure should be reconsidered for use in this program.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant.The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this programYes. MAP has previously noted the relationship between care coordination and avoidable readmissions.[i] One study found that estimated a 30-day unplanned all-cause readmission rate of 14.6% for cancer patients, noting that cancer patients were more likely to be readmitted compared to other inpatient populations. [ii] Another study found that while a majority of cancer-related readmissions may not be preventable, 33% could be prevented through improved care coordination.[iii] Including an unplanned readmissions measure for cancer patients, may also begin to fill the gap related to cost. In its Affordability Family of measures, MAP noted readmissions as an important driver of affordability and noted that reducing preventable readmissions could help address healthcare spending. The Institute of Medicine also noted preventable readmissions as a key cost driver.[iv] [i] NQF. MAP Families of Measures: Safety, Care Coordination, Cardiovascular Conditions, Diabetes. October 2012. [ii] Ji, Hong et al. All-Cause Readmission to Acute Care for Cancer Patients. Healthcare Quarterly, 15(3) July 2012: 14-16.doi:10.12927/hcq.2013.23044[iii] Brown et al. Hospital Readmissions: Necessary Evil or Preventable Target for Quality Improvement. Annals of Surgery :October 2014 - Volume 260 - Issue 4 - p 583–591[iv] IOM. The Healthcare Imperative.: Lowering Costs and Improving Outcomes – Workshop Series Summary. Washington, DC:National Academies Press; 2011.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. No. It is currently in alpha testing. Measure will be assessed using the measure under development pathway.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? No. Yes, readmissions are not currently measures in the PCHQR program. Reducing readmissions improves quality and reduces costs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Readmission rates can be used
as a source of both quality improvement and cost containment, contributing to
the triple aim of the Patient Protection and Affordable Care Act; better health,
better care, and lower healthcare costs for patients. The many facets and
subsequent variation of readmissions across facilities demonstrate the need for
a standardized methodology of data collection. Moreover, differentiation between
organic disease and complications (potentially requiring reoperation) is
necessary to accurately determine quality of care (Brown et al.). The proposed
measure addresses a cancer-specific patient population, specified for PPS-Exempt
Cancer Centers operating within the United States. The reduction in variability
for patient diagnoses as well as care setting promotes the development of an
optimized measure to yield the greatest benefit to patients (i.e., one that has
been specified for their unique conditions/diagnoses). For the purpose of this
measure, “costs” should be understood to comprehensively include 1. The
physiologic, psychologic, and monetary detriment to the patient 2. Financial
cost to the institution, and 3. Potential cost to the practicing surgeon (when
higher readmission rates are used as surrogates for substandard care in quality
improvement circles) (Brown et al). The outcome measured counts the number of
all unplanned readmissions for patients who meet the specified denominator
criteria. Unplanned readmissions are captured from acute clinical events
requiring urgent re-hospitalization within 30 days of discharge (from an index
admission). This standardized time frame is necessary so that patients may be
uniformly compared, and the 30-day time frame is chosen for its proven clinical
significance in readmission rates (see attached references). Note that a
readmission is also eligible as an index admission if it meets all other
eligibility criteria. If the first admission after discharge is planned, then no
readmission is considered in the outcome, regardless of whether a subsequent
unplanned readmission takes place because it would be unfair to attribute the
unplanned readmission back to the care received during the index admission
(consistent with NQF-endorsed measure #1789; 30-Day Hospital-Wide All-Cause
Unplanned Readmission, which excludes patients admitted to a PPS-Exempt Cancer
Center and patients receiving medical treatment for cancer).
| Administrative Communication for program(s): OQR (MUC ID: E0291) |
NQF Number (if applicable): 0291
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure identifies whether the medical record documentation indicates that administrative information was communicated to the receiving facility prior to departure.Critical Objectives: Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: No Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven subcomponents from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Communication problems are a
major contributing factor to adverse events in hospitals, accounting for 65% of
sentinel events tracked by the Joint Commission (JCAHO 2007). In addition,
research indicates that deficits exist in the transfer of patient information
between hospitals and primary care physicians in the community (Kripalani S
2007), and between hospitals and long term facilities (Cortes T 2004). The Joint
Commission has adopted National Patient Safety Goal #2, “Improve the
Effectiveness of Communication Among Caregivers.” Requirement 2E for this goal
requires
| Advance Care Plan for program(s): ASCQRP (MUC ID: E0326) |
NQF Number (if applicable): 0326
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This high impact fully specified endorsed measure is currently in several federal programs, fills the measurement gap of patient and family engagement measures, and is part of multiple NQF Families of Measures, such as Care Coordination, Dual Eligible Beneficiaries, and Hospice.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is used in multiple public programs and fulfills the ambulatory measurement gap of patient and family engagement. Advance care planning (ACP) is an iterative process, typically throughout the medical relationship, where a patient’s current condition and diagnosis are reviewed. Often during this discussion, medical issues are raised, and options examined. Ideally, the clinician, the patient, and his or her loved ones will discuss and analyze possible options to explore in the case that a patient’s health deteriorates.Critical Objectives: Include measures that have high impact and are meaningful to patients.This measure is highly impactful and meaningful to patients. Advance care planning is a process where a patient’s current condition and prognosis are reviewed, likely medical dilemmas are presented, and options discussed. In an ideal ACP discussion, clinicians, the patient, and his or her loved ones think through particular approaches to follow if (or when) the patient’s health declines. This process is iterative and typically occurs longitudinally within the context of an existing and continuing medical relationship. This measure is consistent with the Patient Self Determination Act (PSDA), approved in 1990, affecting Medicare beneficiaries. The act requires that beneficiaries be informed about their rights to self-determination and the use of advance directives as well as identifies particular facilities accountable for providing the information. However, recent studies show that majority of patients are not having advanced care planning conversations with their providers and/or caregivers.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.The measure is currently used in Physician Feedback and Physician Quality Reporting System (PQRS), and under review for the Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority measure gaps.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure under consideration has been tested in the ambulatory setting.
Is the measure currently in use? No. This measure under consideration is currently in use in PQRS and Physician Feedback.
Does the measure promote alignment and parsimony? Yes. This measure supports alignment across programs by currently being used in several federal programs, filling the measurement gaps in the ambulatory setting of patient and family engagement measures, and being part of multiple NQF Families of Measures, such as Care Coordination, Dual Eligible Beneficiaries, and Hospice.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: This measure would be
consistent with a legislative mandate affecting Medicare beneficiaries, the
Patient Self Determination Act (PSDA), approved in 1990. The act requires that
beneficiaries be informed about their rights to self-determination and the use
of advance directives, and identifies particular facilities accountable for
providing the information. Despite this, a recent cancer research study had
found that most patients had not spoken extensively to health professionals or
close persons about the future. Furthermore, a recent meta-analysis found that
awareness of patients´ and surrogates´ decision-making characteristics and
communication styles can help clinicians identify potential barriers and
variations in patterns of communication. To that end, the authors contend that
initial and ongoing assessments of patients´ and surrogates´ communication style
and characteristics must be incorporated into the plan of care (Melhado 2011). A
cross-sectional study out of Oklahoma found that among community dwelling older
persons, a living will is a positive first step towards healthcare planning and
designating a power of attorney. They also found that the state’s effort to
increase the use of advance directives among older residents was successful,
indicating that organizations have the power to influence people with respect
ACP (Mcauley 2008). An observational study from La Crosse County, Wisconsin
found that a system for ACP can be managed in a geographic region so that, at
the time of death, almost all adults have an advance care plan that is specific
and available and treatment is consistent with their plan. The data from this
study suggest that quality efforts have improved the prevalence, clarity, and
specificity of ACPs (Hammes 2010). Barnes KA, Barlow CA, Harrington J, Ornadel
K, Tookman A, King M, & Jones L. (2011). Advance Care Planning Discussions
in Advanced Cancer: Analysis of Dialogues Between Patients and Care Planning
Mediators. Palliative & Supportive Care;9(1):73-9. Basanta WE. (2002).
Advance Directives and Life-Sustaining Treatment: A Legal Primer.
Hematology/Oncology Clinics of North America;16(6):1381-96. Garand L, Drew MA,
Lingler JH, & DeKosky ST. (2011). Incidence and Predictors of Advance Care
Planning Among Persons With Cognitive Impairment. American Journal of Geriatric
Psychiatry;18(8):712-20. Hammes BJ, Rooney BL, & Gundrum JD. (2010). A
Comparative, Retrospective, Observational Study of the Prevalence, Availability,
and Specificity of Advance Care Plans in a County that Implemented an Advance
Care Planning Microsystem. Journal of the American Geriatrics
Society;58(7):1249-55. Mcauley WJ, McCutheon ME, & Travis SS. (2008).
Advance Directives for Health Care Among Older Community Residents. Journal of
Health & Human Services Administration, 30(4), 402-419. Melhado LW &
Byers JF. (2011). Patients’ and Surrogates’ Decision-Making Characteristics
Withdrawing, Withholding, and Continuing Life-Sustaining Treatments. Journal of
Hospice & Palliative Nursing;13(1):16-28. Sampson EL, Jones L, Thune-Boyle
IC, Kukkastenvehmas R, King M, Leurent B, Tookman A, & Blanchard MR.
Palliative assessment and advance care planning in severe dementia: An
exploratory randomized controlled trial of a complex intervention. Palliative
Care;25(3):197-209. Sanders A, Schepp M, & Baird M. (2011). Partial
do-not-resuscitate orders: A Hazard to Patient Safety and Clinical Outcomes?
Critical Care Medicine;39(1):14-8. Tung EE, Vickers KS, Lackore K, Cabanela R,
Hathaway J, & Chaudhry R. (2011). Clinical Decision Support Technology to
Increase Advance Care Planning in the Primary Care Setting. American Journal of
Hospice and Palliative Medicine;28(4):230-5.
| Advance Care Plan for program(s): OQR (MUC ID: E0326) |
NQF Number (if applicable): 0326
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses an important aspect of patient engagement, promotes alignment across programs, and is NQF-endorsed.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is highly impactful and meaningful to patients that is used in multiple public programs and fulfills many ambulatory measurement gaps such patient and family engagement and follow-up after procedures. Advance care planning (ACP) is an iterative process, typically throughout the medical relationship, where a patient’s current condition and diagnosis are reviewed. Often during this discussion, medical dilemmas are raised, and options examined. Ideally, the clinician, the patient, and his or her loved ones will discuss and analyze possible tactics to explore in the case that the patient’s health deteriorates.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. The measure is currently used in Physician Feedback and Physician Quality Reporting System (PQRS), and under review for the Ambulatory Surgical Center Quality ReportingSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Yes- patient and family engagement and follow-up after procedures
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested in the ambulatory setting.
Is the measure currently in use? Yes. This measure supports alignment across programs by currently being used in several federal programs, filling the measurement gaps in the ambulatory setting of patient and family engagement and follow-up after procedures, and being part of multiple NQF Families of Measures, such as Care Coordination, Dual Eligible Beneficiaries, and Hospice.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: This measure would be
consistent with a legislative mandate affecting Medicare beneficiaries, the
Patient Self Determination Act (PSDA), approved in 1990. The act requires that
beneficiaries be informed about their rights to self-determination and the use
of advance directives, and identifies particular facilities accountable for
providing the information. Despite this, a recent cancer research study had
found that most patients had not spoken extensively to health professionals or
close persons about the future. Furthermore, a recent meta-analysis found that
awareness of patients´ and surrogates´ decision-making characteristics and
communication styles can help clinicians identify potential barriers and
variations in patterns of communication. To that end, the authors contend that
initial and ongoing assessments of patients´ and surrogates´ communication style
and characteristics must be incorporated into the plan of care (Melhado 2011). A
cross-sectional study out of Oklahoma found that among community dwelling older
persons, a living will is a positive first step towards healthcare planning and
designating a power of attorney. They also found that the state’s effort to
increase the use of advance directives among older residents was successful,
indicating that organizations have the power to influence people with respect
ACP (Mcauley 2008). An observational study from La Crosse County, Wisconsin
found that a system for ACP can be managed in a geographic region so that, at
the time of death, almost all adults have an advance care plan that is specific
and available and treatment is consistent with their plan. The data from this
study suggest that quality efforts have improved the prevalence, clarity, and
specificity of ACPs (Hammes 2010). Barnes KA, Barlow CA, Harrington J, Ornadel
K, Tookman A, King M, & Jones L. (2011). Advance Care Planning Discussions
in Advanced Cancer: Analysis of Dialogues Between Patients and Care Planning
Mediators. Palliative & Supportive Care;9(1):73-9. Basanta WE. (2002).
Advance Directives and Life-Sustaining Treatment: A Legal Primer.
Hematology/Oncology Clinics of North America;16(6):1381-96. Garand L, Drew MA,
Lingler JH, & DeKosky ST. (2011). Incidence and Predictors of Advance Care
Planning Among Persons With Cognitive Impairment. American Journal of Geriatric
Psychiatry;18(8):712-20. Hammes BJ, Rooney BL, & Gundrum JD. (2010). A
Comparative, Retrospective, Observational Study of the Prevalence, Availability,
and Specificity of Advance Care Plans in a County that Implemented an Advance
Care Planning Microsystem. Journal of the American Geriatrics
Society;58(7):1249-55. Mcauley WJ, McCutheon ME, & Travis SS. (2008).
Advance Directives for Health Care Among Older Community Residents. Journal of
Health & Human Services Administration, 30(4), 402-419. Melhado LW &
Byers JF. (2011). Patients’ and Surrogates’ Decision-Making Characteristics
Withdrawing, Withholding, and Continuing Life-Sustaining Treatments. Journal of
Hospice & Palliative Nursing;13(1):16-28. Sampson EL, Jones L, Thune-Boyle
IC, Kukkastenvehmas R, King M, Leurent B, Tookman A, & Blanchard MR.
Palliative assessment and advance care planning in severe dementia: An
exploratory randomized controlled trial of a complex intervention. Palliative
Care;25(3):197-209. Sanders A, Schepp M, & Baird M. (2011). Partial
do-not-resuscitate orders: A Hazard to Patient Safety and Clinical Outcomes?
Critical Care Medicine;39(1):14-8. Tung EE, Vickers KS, Lackore K, Cabanela R,
Hathaway J, & Chaudhry R. (2011). Clinical Decision Support Technology to
Increase Advance Care Planning in the Primary Care Setting. American Journal of
Hospice and Palliative Medicine;28(4):230-5.
| Adverse Drug Events: - Inappropriate Renal Dosing of Anticoagulants for program(s): IQR (MUC ID: X3323) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure addresse a critical gap in adverse drug events. Anticoagulants are high risk drug classes that should be administered carefully to renal patients, for whom the effects of many drugs differ from non-renal patients. ?
Does the measure address a critical program objective as defined by MAP? Yes. This adverse drug event measure, which is also under for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program, is impactful and meaningful to consumers. Anticoagulants are high risk drug classes that should be administered carefully to renal patients, for whom the effects of many drugs differ from non-renal patients. Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Anticoagulants are one of three high risk drug classes targeted in the National Action Plan for Adverse Drug Event Prevention.Move towards more outcome measures rather than structure or process measures. Process measureAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. Under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access HospitalsEngage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. This measure helps to address the gap of adverse drug events
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No. The measure is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. This measure fills the MAP identified priority gap of adverse drug events.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Additional process measure to
assess medication adverse drug event associated with widely used anticoagulants.
The anticipated effect of implementing this measure would be to reduce or
eliminate inpatient anticoagulant dosing errors that could lead to adverse drug
events (ADEs) for patients with renal impairment. Anticoagulants are one of
three high risk drug classes targeted in the National Action Plan for Adverse
Drug Event Prevention.
| Adverse Drug Events: - Inappropriate Renal Dosing of Anticoagulants for program(s): MUHCAH (MUC ID: X3323) |
NQF Number (if applicable):
Programs under consideration: Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs)
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This adverse drug event measure, which is also under for the Hospital Inpatient Quality Reporting program, focuses on an important safety issue, however, is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Does the measure address a critical program objective as defined by MAP? Yes. This adverse drug event measure, which is also under for the Hospital Inpatient Quality Reporting program, is impactful and meaningful to consumers. Anticoagulants are high risk drug classes that should be administered carefully to renal patients, for whomthe effects of many drugs differ from non-renal patients.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No. Needs Implementation Testing
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. An important safety issue in hospitals and promotes alignment across hospital reporting programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. The measure is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Rationale for measure provided by HHS: Additional process measure to
assess medication adverse drug event associated with widely used anticoagulants.
The anticipated effect of implementing this measure would be to reduce or
eliminate inpatient anticoagulant dosing errors that could lead to adverse drug
events (ADEs) for patients with renal impairment. Anticoagulants are one of
three high risk drug classes targeted in the National Action Plan for Adverse
Drug Event Prevention.
| Ambulatory surgery patients with appropriate method of hair removal for program(s): ASCQRP (MUC ID: E0515) |
NQF Number (if applicable): 0515
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Do not support
Preliminary analysis summary: This measure is topped out with limited performance variation among providers. The measure has been removed from IQR and is not in, nor planned to be, in another program.
Does the measure address a critical program objective as defined by MAP? No. Include measures that have high impact and are meaningful to patients.While appropriate method of hair removal does reduce the likelihood of infections, performance on this measure is topped out. Rates collected for 192 ASCs across the US demonstrated a mean rate of 96% and a median rate of 100%[i]Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure has been removed from IQR and is not in, nor planned to be, in another program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.Response: No [i] http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCAQFjAA&url=http%3A%2F%2Fwww.qualityforum.org%2FProjects%2Fs-z%2FSurgery%2F0515.aspx&ei=8OpkVK_bJ8PbsATj6IIQ&usg=AFQjCNGyJkK8GqLm6aLc4rVQdyL4GtD_0Q&sig2=1eqaPXKGva2DX7NwcJnHSw&bvm=bv.79189006,d.cWc
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: The literature regarding
preoperative hair removal has been systematically reviewed twice, once by
Kjonniksen et al in 2002 and again by Tanner et al in 2007. Three randomized
controlled trials (Alexander et al 1983, Balthazar et al 1983, Ko et al 1992)
compared the rates of infection at the surgical site when hair removal at the
site was performed with clippers or with razors. A statistically significant
difference in infection rates in the pooled results (Tanner et al 2007) was
seen, with 2.8% of the patients who were shaved developing a surgical site
infection compared with 1.4% rate of surgical site infection in the patients who
were clipped. Additional randomized controlled trials (Court-Brown 1981, Powis
et al 1976, Seropian 1971, Thur de Koos 1983) have demonstrated that patients
were more likely to develop a surgical site infection when shaved as compared to
having hair removal with a depilatory. Observational studies have suggested that
no hair removal is less likely to result in surgical site infection, but this
has not been confirmed in randomized controlled trials. The HICPAC/CDC
Guideline for Prevention of Surgical Site Infection (Mangram at al 1999), the
Association of Operating Room Nurses Recommended Practices for Preoperative
Patient Skin Antisepsis (AORN 2002) and the SHEA/IDSA Strategies to Prevent
Surgical Site Infections in Acute Care Hospitals (Anderson et al 2008) are
consistent with the intent of this measure. Alexander JW, Fischer JE, Boyajian
M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound
infections. Arch Surg. 1983 Mar;118(3):347-52. Anderson DJ, Kaye KS, Classen D,
Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V,
Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA,
Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe
DS. Strategies to prevent surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61. Association of
Operating Room Nurses. Recommended practices for skin preparation of patients.
AORN J. 2002 Jan;75(1):184-7. Balthazar ER, Colt JD, Nichols RL. Preoperative
hair removal: a random prospective study of shaving versus clipping. South Med
J. 1982 Jul;75(7):799-801. Court-Brown CM. Preoperative skin depilation and its
effect on postoperative wound infections. J R Coll Surg Edinb. 1981
Jul;26(4):238-41. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L.
Preoperative hair removal--a systematic literature review. AORN J. 2002
May;75(5):928-38, 940. Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH.
Effects of shaving methods and intraoperative irrigation on suppurative
mediastinitis after bypass operations. Ann Thorac Surg. 1992 Feb;53(2):301-5.
Powis SJ, Waterworth TA, Arkell DG. Preoperative skin preparation: clinical
evaluation of depilatory cream. Br Med J. 1976 Nov 13;2(6045):1166-8. Seropian
R, Reynolds BM. Wound infections after preoperative depilatory versus razor
preparation. Am J Surg. 1971 Mar;121(3):251-4. Tanner J, Moncaster K, Woodings
D. Preoperative hair removal to reduce surgical site infection. Cochrane
Database Syst Rev. 2006 Jul 19;3:CD004122. Thur de Koos P, McComas B. Shaving
versus skin depilatory cream for preoperative skin preparation. A prospective
study of wound infection rates. Am J Surg. 1983 Mar;145(3):377-8.
| AMI episode of care (inpatient hospitalization + 30 days post-discharge) for program(s): HVBP (MUC ID: X2698) |
NQF Number (if applicable): N/A
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: This is a high priority (per
episode) resource use measure. AMI is a condition with a substantial range in
costs of care and for which there are well-established publicly reported quality
measures; therefore, it is an ideal condition for assessing relative value for
an episode of care that begins with an acute hospitalization. Moreover, AMI is
one of the leading cause of hospitalization for Americans over 65 years old and
costs the US roughly $18 billion annually. Medicare payments are difficult to
interpret in isolation. Some high payment hospitals may have better clinical
outcomes when compared with low payment hospitals; other high payment hospitals
may not. For this reason, the value of hospital care is more clearly assessed
when pairing hospital payments with hospital quality. A measure of payments for
Medicare patients during an episode of care for AMI aligned with current quality
of care measures will facilitate profiling hospital value (payments and
quality). This measure, which uses standardized payments, reflects differences
in the management of care for patients with AMI both during hospitalization and
immediately post-discharge. By focusing on one specific condition, value
assessments may provide actionable feedback to hospitals and incentivize
targeted improvements in care. This measure is harmonized with NQF E0230.
| Anesthesiology Smoking Abstinence for program(s): MSSP (MUC ID: X3811) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Do not encourage further consideration
Preliminary analysis summary: Smokingcessation is an important area of measurement; however single day abstinence does not reflect the objective of a high value measure of health risk with follow-up intervention.
Does the measure address a critical program objective as defined by MAP? Yes. Smokingcessation is an important area of measurement; however single day abstinence does not reflect the objective of a high value measure of health risk with follow-up intervention.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure has limited potential toaddress the objective of a high value measure of health risk with follow-up intervention for Medicare beneficaires.· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure doesn’t directly address the rate of growth of healthcare spending. · Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not measure care across settings or providers. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is currently under consideration in PQRS-based programs. If it is selected for use in these programs, this can promote alignment in the future. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure has limited potential toaddress the objective of a high value measure of health risk with follow-up intervention for Medicare beneficaires
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Each year, millions of
cigarette smokers require surgery and anesthesia in the US. Smoking is a
significant independent risk factor for perioperative heart, lung, and
wound-related complications. There now is good evidence that perioperative
abstinence from smoking reduces the risk of heart, lung, and wound-related
perioperative complications, and that the perioperative period represents a
“teachable moment” for smoking cessation that improves long-term abstinence
rates; over 100,000 smokers quit in the US each year as a result of having a
surgical procedure. Although evidence suggests that the longer the duration of
abstinence the better, there is also evidence that even brief abstinence (e.g.,
abstaining from smoking on the morning of surgery) can dramatically reduce both
nicotine and carbon monoxide levels and reduce risks for complications such as
intraoperative myocardial ischemia. Evidence shows that tobacco interventions
can 1) increase perioperative abstinence rates in surgical patients who smoke
and 2) decrease the rate of perioperative complications. Thus, this measure,
which incents the provision of tobacco interventions by clinicians as a part of
routine clinical practice, will significantly improve the health of smokers who
require surgery. In its Clinical Practice Guideline for Treating Tobacco Use and
Dependence, the US Public Health Services recognizes the important role that
clinicians play in delivering tobacco use intervention services, strongly
recommending that clinicians screen all adults for tobacco use and provide
tobacco cessation interventions for those who use tobacco products.
| At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer for program(s): PCHQR (MUC ID: E0225) |
NQF Number (if applicable): 0225
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS Exempt Cancer HQRP, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Colorectal cancer is a leading cause of cancer-related death in the U.S., expected to cause over 50,000 deaths in 2014.[i] A surgical resection is currently the only curative treatment for localized colon cancer. [ii] Lymph node counts after resection for colon cancer are closely related to survival rates and guidelines recommend the removal and assessment of at least 12 lymph nodes.[iii] Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant.N/A. This measure is not used in any other federal program. The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this programWhile this measure does not directly assess colon cancer survival, removal of at least 12 lymph nodes is associated with increased rates of survival. [i] American Cancer Society. Last Revised 1/31/2014. http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-key-statistics[ii] 2014 UptoDate. Surgical oncologic principles for the resection of colon cancer. Summary and Recommendations. [iii] 2014 UptoDate. Surgical oncologic principles for the resection of colon cancer. Summary and Recommendations.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure has been tested and is being used in hospital/acute care facilities.
Is the measure currently in use? Yes. Yes,this measure is used by the American College of Surgeons’ Commission on Cancer. This measure has been in use by the Commission on Cancer since 2007.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? . Yes.The measure is not duplicative of an existing measure. While this measure is not currently included in another federal program, it is part of the MAP Cancer Family of Measures. This measure would help to address a gap in colon cancer care previously identified by the Hospital Workgroup.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is a NQF-endorsed measure (#0225).
Rationale for measure provided by HHS: CoC-accredited (Commission on
Cancer) facilities are eligible to submit data for this measure. This is a
Quality Improvement measure and has already been endorsed by the CoC. Improved
survival for patients with a greater number of lymph nodes resected ;greater
accuracy of staging for patients, and consequently appropriate post-surgical
care Chang GJ, Rodriguez-Bigas MA Skibber JM et al. Lymph node evaluation and
survival after curative resection of colon cancer: systematic review. JNCI 2007;
99(6)L433-441. 2. Le Voyer TE, Sigurdson ER, Hamlin AL et al. Colon cancer
survival is associated with increasing number of lymph nodes analyzed: a
secondary survey of intergroup trial INT-0089. J Clin Oncol 2003; 21:2912-2919.
3. Sarli L, Bader G, Lusco D, et al. Number of lymph nodes examined and
prognosis of TNM stage II colorectal cancer. European Journal of Cancer 2005;
41:272-279. 4. Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of
T3N0 clon cancer is dependent on the number of lymph nodes examined. Ann Surg
Oncol 2003; 10(1):65-71
| Cardiac Rehabilitation Patient Referral From an Inpatient Setting for program(s): IQR (MUC ID: E0642) |
NQF Number (if applicable): 0642
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure would address a known gap in care transitions and referrals to the next site of care.Cardiac rehabilitation has been found to be underused, despite being included in the American Heart Association Get with the Guidelines program. ?
Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses referral to a frequently underutilized follow-up service that has been shown to improve patient outcomes and quality of life.Critical Objectives:?Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.?Yes, Cardiac rehabilitation has been shown to improve patient outcomes, including quality of life, risk of recurrence, function and mortality.Move towards more outcome measures rather than structure or process measures.?N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.?N/A?Engage patients and families as partners in their care.?N/A?Expand the program to include measures that allow rural and other small hospitals to participate.?N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses care transitions and appropriate referral to the next site of care. Cardiac rehabilitation has been found to be underused, despite being included in the American Heart Association Get with the Guidelines program. Variations have been associated with geographical location, as well as by socioeconomic status, gender, and age.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the appropriate care setting and level of analysis for this program.
Is the measure currently in use? Yes. Yes. This measure is currently in use in American Association of Cardiovascular and Pulmonary Rehabilitation Registry.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes. This measure addresses a known gap in quality and is part of the MAP Cardiovascular Disease Family of Measures
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes. This is NQF #0642 –Cardiac Rehabilitation Referral from inpatient setting
Rationale for measure provided by HHS: Cardiac
rehabilitation/secondary prevention programs (CR/SP) improve patient outcomes,
including quality of life, function, recurrent myocardial infarction, and
mortality. 2. CR/SP is underutilized with geographic variability and decreased
participation by patients with economic disadvantages, women and older patients.
3. The CR/SP performance measures were developed for use in systematic quality
improvement projects to close this treatment gap. 4. Use of systematic referral
processes and tools have been shown to increase CR/SP referral. 5. Enrollment
and participation in CR/SP, not referral, have been shown to improve patient
outcomes. However, referral is necessary for patients to enroll and participate
in CR/SP. The strength of provider referral to CR has been shown to correlate
with participation in CR.
| Cellulitis Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0354) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Cellulitis Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0354) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional Support pending NQF review and endorsement
Preliminary analysis summary: This measure addresses the cost of care for a common but potentially serious skin infection. Costs for cellulitis can be significant if hospitalization is required.?
Does the measure address a critical program objective as defined by MAP? Yes. Yes, this measure addresses the cost of care for a common but potentially serious skin infection. Costs for cellulitis can be significant if hospitalization is required.Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Yes, while only a small subset of patients is hospitalized cellulitis each year, the costs of treatment can be high if a patient is hospitalized for this condition.[i] Move towards more outcome measures rather than structure or process measures.N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.N/AEngage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses cost. Cellulitis is a common, potentially serious skin infection. Treatment is usually oral antibiotics[i] however hospitalization may be required for severe infections[ii] leading to significant costs.[iii] [i] http://www.mayoclinic.org/diseases-conditions/cellulitis/basics/definition/con-20023471[ii] http://www.uptodate.com/contents/skin-and-soft-tissue-infection-cellulitis-beyond-the-basics?source=see_link[iii] Acumen. Methodology for Developing the Six Hospital-based Episode Measures: Supplemental Documentation for the Fiscal Year 2015 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing[i] Acumen. Methodology for Developing the Six Hospital-based Episode Measures: Supplemental Documentation for the Fiscal Year 2015 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure could help to address the variation in costs in a common condition.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Death among surgical inpatients with serious, treatable complications (PSI 4) for program(s): HVBP (MUC ID: E0351) |
NQF Number (if applicable): 0351
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure is NQF-endorsed, has been prioritized by MAP for inclusion in the VBP program, and addresses a number of important and improvable patient safety concerns.
Does the measure address a critical program objective as defined by MAP? . Critical Program ObjectivesInclude measures where there is a need and opportunity for improvement. Yes. Per Hospital Compare, the U.S. national rate on this measure is 110.25 per 1,000 patient discharges. The NQF Surgery Standing Committee determined that there is opportunity and ability to improve the results of this measure.[i] Emphasize areas of critical importance for high performance and quality improvement, and ideally, link clinical quality and cost measures to capture value.Yes, in its 2014 pre-rulemaking recommendations MAP recommended the prioritization of this measure for the VBP program. NQF-endorsed measures are strongly preferredYes, this measure is NQF-endorsed. Keep the program measure set parsimonious to avoid diluting the payment incentives. N/AMAP identified a number of gap areas that should be addressed within the VBP program measure set, including medication errors, mental and behavioral health, emergency department throughput, a hospital’s culture of safety, and patient and family engagement.Yes, the measure addresses a number of important patient safety concerns. [i] NQF. Surgery Endorsement Maintenance 2010
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, the measure is appropriate for the facility level.
Is the measure currently in use? Yes. Yes, this measure is included in the MAP Safety Family of Measures.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Aligned with the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Silber and colleagues have
published a series of studies establishing the construct validity of failure to
rescue rates through their associations with hospital characteristics and other
measures of hospital performance. Among patients admitted for cholecystectomy
and transurethral prostatectomy, failure to rescue was independent of severity
of illness at admission, but was significantly associated with the presence of
surgical housestaff and a lower percentage of board-certified
anesthesiologists.31 The adverse occurrence rate was independent of this
hospital characteristic. In a larger sample of 74,647 patients who underwent
general surgical procedures in 1991-92, lower failure to rescue rates were found
at hospitals with high ratios of registered nurses to beds.68 Failure rates were
strongly associated with risk adjusted mortality rates, as expected, but not
with complication rates.143 Finally, among 16,673 patients admitted for coronary
artery bypass surgery, failure rates were lower (whereas complication rates were
higher) at hospitals with magnetic resonance imaging facilities, bone marrow
transplantation units, or approved residency training programs. More recently,
Needleman and Buerhaus, confirmed that higher registered nurse staffing (RN
hours/adjusted patient day) and better nursing skill mix (RN hours/licensed
nurse hours) were consistently associated with lower failure to rescue rates
among major surgery patients from 799 hospitals in 11 states in 1997, even using
administrative data to define complications. An increase from the 25th to the
75th percentile on these two measures of staffing was associated with 5.9% (95%
CI, 1.5% to 10.2%) and 3.9% (95% CI, -1.1% to 8.8%) decreases, respectively, in
the rate of failure-to-rescue among major surgery patients.138 These
associations were inconsistent among medical patients, in that nursing skill mix
was associated with the failure-to-rescue rate (rate ratio 0.81, 95% CI
0.66-1.00) but aggregate registered nurse staffing was not (rate ratio 1.00, 95%
CI 0.99-1.01). An increase from the 25th to the 75th percentile on nursing skill
mix was associated with a 2.5% (95% CI, 0.0% to 5.0%) decrease in the
failure-to-rescue rate among medical patients.
| Door to puncture time for endovascular stroke treatment for program(s): MSSP (MUC ID: X3747) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This intermediate clinical timeliness of appropriate stroke treatment outcome measure is important for a leading cause of mortality and disability for the Medicare fee-for-service population. The measure promotes alignment across the PQRS-based programs.
Does the measure address a critical program objective as defined by MAP? Yes. This measure focuses on important intermediate health outcomes that will improve the quality of stroke treatment for the Medicare FFS population.· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Neurologic conditions and injuries are important clinical conditions that affect millions of Americans each year. Strokes are the fourth leading cause of death in the US and a leading cost of disability. With over 795,000 people suffering from a stroke each year, this is an important measurement areas for the Medicare Fee-For-Service population.[i],[ii],[iii] · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure focus does focus on important intermediate health outcomes that will improve the quality of stroke treatment for the Medicare FFS population. This measure does not directly improve the rate of growth in healthcare spending. · Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure is limited to the door to puncture time within an acute hospitalization, thus has limited applicability across care settings.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is under consideration for all of the PQRS-based programs. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This is an important intermediate clinical outcome measure for a significant number of Medicare beneficiaries but does not address the high-value measurement areas identified by the MAP.[i] Centers for Disease Control. Available at www.cdc.gov/nchs/fastats/stroke.htm. American Stroke Association. Available at www.strokeassociation.org/STROKEORG/AboutStroke/About-Stroke_UCM_308529_SubHomePage.jsp. Last accessed February 2012.[ii] The Internet Stroke Center. Available at www.strokecenter.org/patients/about-stroke/stroke-statistics/. Last accessed February 2012.[iii] American Stroke Association. Available at www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? Yes. This intermediate clinical outcome measure is important for a leading cause of mortality and disability for the Medicare fee-for-service population. The measure also promotes alignment across the PQRS-based programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Acknowledgment of the critical
importance of time to reperfusion for obtaining favorable outcomes in myocardial
reperfusion treatments has led to the formation of initiatives such as Door to
Balloon. The impressive results in shortening the time to myocardial reperfusion
for acute MI obtained by such initiatives provided an impetus for launching
similar initiatives related to IV tPA for stroke. This measures is supported by
the multispecialty guidelines published in 2013 (1). 1. Sacks, D., C. M. Black,
et al. (2013). "Multisociety Consensus Quality Improvement Guidelines for
Intraarterial Catheter-directed Treatment of Acute Ischemic Stroke, from the
American Society of Neuroradiology, Canadian Interventional Radiology
Association, Cardiovascular and Interventional Radiological Society of Europe,
Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European
Society of Minimally Invasive Neurological Therapy, and Society of Vascular and
Interventional Neurology."Journal of vascular and interventional radiology :
JVIR 24(2): 151-163.
| External Beam Radiotherapy for Bone Metastases for program(s): OQR (MUC ID: E1822) |
NQF Number (if applicable): 1822
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: External beam radiation can help provide patients with pain relief. This measure has a demonstrated performance gap and would would begin to expand cancer care measurement to settings beyond the PPS-exempt cancer hospitals.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is high impact with strong supportive evidence base for this intervention, with nearly a 20% performance gap. MAP has previously stressed the importance of expanding cancer care measurement to programs outside of the PPS-Exempt Cancer Hospital Quality Reporting Program.Critical Objectives:Include measures that have high impact and are meaningful to patient.Response:This measure is high impact with a strong supportive evidence base for this intervention. Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: NoSpcific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: No
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the facility level.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. This measure would begin to expand cancer care measurement to settings beyond the PPS-exempt cancer hospitals.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: The measure is developed from
the recommendations by the clinical-practice guideline. This measure is intended
to close the gap in the demonstrated treatment variation and ensure the use of
an appropriate fractionation schedule. The measure also takes into account the
effective schedule for relieving pain from bone metastases, patient preferences
and the time and cost effectiveness. Population: The measure is applicable to
all patients, regardless of age with a diagnosis of painful bone metastases who
are prescribed EBRT unless there is a documented exclusion as specified. 1.
Jeremic B, Shibamoto Y, Acimovic L, et al. A randomized trial of three
single-dose radiation therapy regimens in the treatment of metastatic bone pain.
Int J Radiat Oncol Biol Phys 1998;42:161–167. 2. Bone Pain Trial Working Party.
8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain:
Randomized comparison with a multifraction schedule over 12 months of patient
follow-up. Radiother Oncol 1999;52:111–121. 3. Roos D, Turner S, O’Brien P, et
al. Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy
for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology
Group, TROG 96.05). Radiother Oncol 2005;75: 54–63. 4. Hartsell W, Konski A,
Scott C, et al. Randomized trial of short versus long-course radiotherapy for
palliation of painful bone metastases. J Natl Cancer Inst 2005;97:798–804.
| Falls with injury for program(s): IQR (MUC ID: E0202) |
NQF Number (if applicable): 0202
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending demonstration of applicability at the facility level and resolution of the duplicative nature of this measure with the falls and trauma component of PSI-90. Falls are a common adverse event in hospitals, with estimates of between 2-5 falls per 1,000 patient days, with about 30% of falls result in injury, disability, or death. While falls and trauma are currently addressed in the IQR program in the PSI-90 composite measure, MAP has previously noted that NQF #0141 and #0202 are based off of clinical data and may provide better data than claims-based measures.
Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses falls, a critical patient safety issue for inpatient settings. Although falls are currently measured through PSI-90, this measure has been preferred by MAP in the past.Critical Objectives:??Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, falls are one of the most common causes of patient harm in hospitals.[i]?Move towards more outcome measures rather than structure or process measures.?Yes, this is an outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.NoEngage patients and families as partners in their care.N/A?Expand the program to include measures that allow rural and other small hospitals to participate.?N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. ?Yes, while falls and trauma are currently addressed in the IQR program in the PSI-90 composite measure, MAP has previously noted that NQF #0141 and #0202 are based off of clinical data and may provide better data than claims-based measures. Falls are a common adverse event in hospitals, with estimates of between 2-5 falls per 1,000 patient days.[ii],[iii],[iv] About 30% of falls result in injury, disability, or death.[v] This measure is paired with NQF #0141.[i] http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtoolkit.pdf [ii] Agnostini, J.V., Baker, D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized and institutionalized older people. In Making health care safer: A critical analysis of patient safety practices (pp. 281-299). Evidence Report/Technology Assessment Number 43, AHRQ publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality. [iii] Oliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment. 384, 82. [iv] Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use, restrain orders, and the risk of falls in hospitalized patients. Journal of the American Geriatric Society, 50, 526-529. [v] Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving the capture of fall events in hospitals: Combining a service forevaluating inpatient falls with an incident report system. Journal of the American Geriatric Society, 56, 701-704.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? No. This measure has been tested at the clinician level of analysis. More information is needed on how this would be applied at the facility level.?
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. This measure has been tested at the clinician level of analysis.
Is the measure currently in use? Yes. Yes, this measure is currently used in theMaine Health Management Coalition and Maine Quality Forum Publicly Reported Measures
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is part of the MAP Safety Family of Measures and the MAP Dual Eligible Beneficiaries Family of Measures. This measure also captures a broad population and only excludes pediatrics, psychiatric unit, and obstetrical unit of patients. This is a high value outcome measure that addresses an important safety area. However, falls are currently addressed in the PSI-90 composite included in the IQR measure set. This measure may provide more accurate data but that may need to be balanced with parsimony concerns of adding differing methodologies to the same program. ?
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is NQF #0202 – Falls with Injury
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: The measure focus addresses
several national health goals and priorities, for example: 1. Recently enacted
Centers for Medicare and Medicaid Services regulations limit hospital
reimbursement for care related to fall related injuries. 2. The falls measures
fits within the priorities set forth by the National Priorities Parternship.
Specifically, it fits within the national priority of Making Care Safer
(National Priorities Partnership, 2011). 3. As part of their National Patient
Safety Goals, The Joint Commission requires hospitals to reduce the risk of
patient harm resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini, Baker,
& Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et al., 2002,
2008). In quarter 3 of 2009, fall rates for nursing units in participating NDNQI
hospitals averaged 3.2 per 1000 patient days (median = 2.8 per 1000 patient
days). About 30% of falls result in injury, disability, or death (Shorr, 2008) –
particularly in older adults. Injury falls lead to as much as a 61% increase in
patient-care costs and lengthen a patient’s hospital stay (Fitzpatrick, 2011).
Jorgensen (2011) estimated that by 2020 the direct and indirect costs of
injuries related to falls will reach $54.9 billion. In addition injury falls are
a significant source of liability for hospitals. Agnostini, J.V., Baker, D.I.,
& Bogardus, S.T. (2001). Prevention of falls in hospitalized and
institutionalized older people. In Making health care safer: A critical analysis
of patient safety practices (pp. 281-299). Evidence Report/Technology Assessment
Number 43, AHRQ publication No. 01-E058. Rockville, MD: Agency for Healthcare
Research and Quality. Fitzpatrick, M.A. (2011, March). Meeting the challenge of
fall reduction [Supplement]. American Nurse Today, p. 1. Jorgensen, J. (2011,
March). Reducing patient falls: A call to action [Supplement]. American Nurse
Today, p. 2-3. National Priorities Partnership. (2011, September). Input to the
Secretary of Health and Human Services on Priorities for the National Quality
Strategy. Retrieved from: http://www.qualityforum.org/Home.aspx Oliver, D.,
Connelly, J.B., Victor, C.R. et al. (2007). Strategies to prevent falls and
fractures in hospitals and care homes and effect of cognitive impairment. 384,
82. Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use, restrain
orders, and the risk of falls in hospitalized patients. Journal of the American
Geriatric Society, 50, 526-529. Shorr, R.I., Mion, L.C., Chandler, M., et al.
(2008). Improving the capture of fall events in hospitals: Combining a service
for evaluating inpatient falls with an incident report system. Journal of the
American Geriatric Society, 56, 701-704. Unruh, L. (2002). Tends in adverse
events in hospitalized patients. Journal of Healthcare Quality, 24, 4-10.
| Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0355) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0355) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional Support pending NQF review and endorsement
Preliminary analysis summary: GI bleeding is a common and costly condition. GI bleeding is responsible for more hospitalizations that congestive heart failure or deep vein thrombosis. An episode-based approach could help drive improvement in both cost and quality
Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses the cost of care for a condition that causes a large number of hospitalizations annually.Critical Objectives:Choose high impactmeasures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, GI bleeding is a common and costly condition. GI bleeding is responsible for more hospitalizations that congestive heart failure or deep vein thrombosis[i]. An episode-based approach could help drive improvement in both cost and quality.[ii]Move towards more outcome measures rather than structure or process measures.?N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.?N/AEngage patients and families as partners in their care.N/A?Expand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses the cost of care. The estimated annual hospitalization rate for upper GI bleeding is 165 per 100,000[iii]. This translates to over 300,000 hospitalizations annually, costing over $2.5 billion.[iv],[v] Costs have been found to be primarily related to inpatient hospitalizations.[vi] However, GI hemorrhage can be caused by a number of underlying conditions and the costs can vary significantly by type of GI bleeding[vii]. [i] Albeldawi M., Qadeer MA, Vargo JJ. Managing acute upper GI bleeding, preventing recurrences. Cleveland Clin J Med. 2010; 77(2):131-142. [ii] http://content.healthaffairs.org/content/28/5/1406.full.pdf [iii] Albeldawi M., Qadeer MA, Vargo JJ. Managing acute upper GI bleeding, preventing recurrences. Cleveland Clin J Med.2010; 77(2):131-142. [iv] Viviane A, Alan BN. Estimates of costs of hospital stays for variceal and nonvariceal upper gastrointestinal bleeding in the United States. Value Health 2008; 11:1–3. [v] Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia A, Amundson DE. Analysis of 3,294 cases of uppergastrointestinal bleeding in military medical facilities. Am J Gastroenterol 1995; 90:568–573. [vi] Cryer BL1, Wilcox CM, Henk HJ, Zlateva G, Chen L, Zarotsky V. The economics of upper gastrointestinal bleeding in a US managed-care setting: a retrospective, claims-based analysis. J Med Econ. 2010 Mar;13(1):70-7. doi: 10.3111/13696990903526676. [vii] Viviane A, Alan BN. Estimates of costs of hospital stays for variceal and nonvariceal upper gastrointestinal bleeding in the United States. Value Health 2008; 11:1–3.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure could help to address the variation in costs in a common condition.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Health literacy measure derived from the health literacy domain of the C-CAT for program(s): OQR (MUC ID: E1898) |
NQF Number (if applicable): 1898
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This outcome measure addresses an important aspect of patient and family engagement.
Does the measure address a critical program objective as defined by MAP? Yes. This is a high impact measure that is meaningful to patients since it is a measure that focuses on health literacy related to patient-centered communication, derived from staff and patient responses.Critical Objectives:Include measures that have high impact and are meaningful to patients. Ensuring that each person and family is engaged as partners in their care.Yes, health literacy is key engaging patients as partners in their care.Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module. Response: Fills a gap in patient and family engagement
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested in the ambulatory setting and facility level of analysis.
Is the measure currently in use? No. This measure is currently not used in any public programs.
Does the measure promote alignment and parsimony? Yes. This patient and family engagement outcome measure contributes to the efficient use of measurement resources and supports alignment across programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Evidence generated through
national validation study of C-CAT instrument, including surveys of patients and
staff. Results of study demonstrated that better scores on the measure of health
literacy is correlated to important indicators of health care quality.
Multivariate analysis showed that a 5-point increase in the measure results in
more than a 1/3 greater odds that patients would report receiving high-quality
medical care (OR 1.40, 95% CI 1.22-1.61) and a more than 25% greater odds that
patients would report a belief that their medical records are kept private (OR
1.28, 95% CI 1.10-1.47). Likewise, a 5-point increase in the measure score is
correlated with a more than 25% decrease in the odds a patient would believe
that a mistake made in their care would be hidden from them (OR 0.73, 95% CI
0.62-0.86). Additional evidence of the importance of health literacy to
patient-centered communication from Improving Communication -- Improving Care:
How Health Care Organizations Can Ensure Effective, Patient-Centered
Communication with People from Diverse Populations.
http://www.ama-assn.org/resources/doc/ethics/pcc-consensus-report.pdf
| Hip Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0356) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Hip Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0356) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Hospice and Palliative Care – Treatment Preferences for program(s): PCHQR (MUC ID: E1641) |
NQF Number (if applicable): 1641
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant.The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this programYes. MAP has previously stressed the importance of palliative care and treatment preferences in hospital performance measurement programs. In the 2014 Pre-Rulemaking Report, MAP suggested HHS look to this measures to fill a gap in the PCHQR program.Control over treatment preferences is a high priority for patients and their families/caregivers.[i] Communication about treatment preferences has been associated with greater use of treatments in line with patient preferences and with decreased use of aggressive and high-cost treatments.[ii],[iii] [i] Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients´ perspective. JAMA 1999; 281: 163-168.[ii]Wright AA, Mack JW, Kritek PA, Balboni TA, Massaro AF, Matulonis UA, Block SD, Prigerson HG. Influence of patients’preferences and treatment site on cancer patients’ end of life care. Cancer. 2010 Oct 1;;116(19):4656-63.[iii]Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions, patient mental health, medical care near death,and caregiver bereavement adjustment. JAMA 2008; 300:1665-1673.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, it is tested for the hospital setting/acute care facility level.
Is the measure currently in use? Yes. Yes. This measure is currently in use in the Hospice Quality Reporting Program. This measure is used by the Visiting Nurse Service of New York.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is not duplicative of an existing measure in the PCHQR measure set. This measure would begin to fill previously identified gaps in treatment preferences and palliative care.It is part of the MAP Hospice and Palliative Care Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #1641.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: The National Priorities
Partnership has identified palliative and end-of-life care as one of its
national priorities. A goal of this priority is to ensure that all patients with
life-limiting illness have the right to express preferences that guide use of
invasive or life-sustaining forms of treatment.(1) The affected populations are
large; in 2009, 1.56 million people with life-limiting illness received hospice
care.(2) In 2008, 58.5% of US hospitals with 50 or more beds had some form of
palliative care service, and national trends show steady expansion of these
services.(3) Patients and family caregivers rate control over treatment
decisions as a high priority when living with serious and life-limiting
illnesses. (4) From a recent systematic review of clinical trials, moderate
evidence supports "care planning through engaging values, involving skilled
facilitators, and focusing on key decision makers.” These studies found improved
outcomes of patient-physician communication, improved satisfaction with care,
and increased hospice enrollment.(5) The more recently published Coping with
Cancer Study, a prospective observational study of over 300 patients with
advanced cancer, found that communication of patient treatment preferences was
associated with use of treatments honoring those preferences and wish lesser use
of aggressive, high-cost treatments.(6,7) This measure will enhance patient
autonomy, facilitate patient-centered decision-making, and communicate patient
preferences via documentation to other treating providers.
1.http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=608 2.
NHPCO Facts and figures: hospice care in America 2010 edition
http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf
3. Center to Advance Palliative Care
http://www.capc.org/news-and-events/releases/04-05-10 4.Singer PA, Martin DK,
Kelner M. Quality end-of-life care: patients´ perspective. JAMA 1999; 281:
163-168. 5. Lorenz KA, Lynn J, Dy SM et al. Evidence for improving palliative
care at the end of life: a systematic review. Ann Intern Med 2008: 148:147-159.
6. Wright AA, Mack JW, Kritek PA, Balboni TA, Massaro AF, Matulonis UA, Block
SD, Prigerson HG. Influence of patients’ preferences and treatment site on
cancer patients’ end of life care. Cancer. 2010 Oct 1;?116(19):4656-63. 7.
Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions,
patient mental health, medical care near death, and caregiver bereavement
adjustment. JAMA 2008; 300:1665-1673.
| Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization for program(s): HVBP (MUC ID: E1893) |
NQF Number (if applicable): 1893
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: Support
Preliminary analysis summary: The VBP program currently includes 30 day mortality rates for AMI, heart failure, and pneumonia. COPD is another leading cause of death and hospitalization. This measure is currently used in the IQR program thus supporting alignment and parsimony.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Program ObjectivesInclude measures where there is a need and opportunity for improvement. Yes: In the 2013 Hospital Quality Chartbook, CMS noted an 18% increase in the number of people hospitalized for COPD between 1998 and 2008[i]. In its review of this measure, the NQF Pulmonary and Critical Care Steering Committee noted the significant mortality for COPD and the significant opportunity for improvement on this measure.[ii] In the 2013 Hospital Quality Chartbook, CMS included results from the dry run of this measure. Mortality rates declined from 2009 to 2011 (7.9%-7.7%) but the wide distribution (13.0% maximum to 4.3% minimum) suggests opportunity for improvement[iii]. Emphasize areas of critical importance for high performance and quality improvement, and ideally, link clinical quality and cost measures to capture value. Yes: COPD is the third leading cause of death in the United States with annual costs of approximately $50 billion dollars[iv]. The American Lung Association noted that in 2010 COPD was responsible for over 700,000 hospital discharges.[v] MAP recommended the prioritization of this measure for the VBP program in its 2014 pre-rulemaking recommendations. NQF-endorsed measures are strongly preferred.Yes: this measure is NQF-endorsed. Keep the program measure set parsimonious to avoid diluting the payment incentives.Yes: this is an important outcome measure for a condition affecting a large number of patients and responsible for a large number of hospitalizations.MAP identified a number of gap areas that should be addressed within the VBP program measure set, including medication errors, mental and behavioral health, emergency department throughput, a hospital’s culture of safety, and patient and family engagement.No: COPD mortality was not identified as a gap area for the VBP program. [i] http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/-Medicare-Hospital-Quality-Chartbook-2013.pdf[ii] NQF. Pulmonary and Critical Care Consensus Standards Endorsement Maintenance. 2013.[iii] http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/-Medicare-Hospital-Quality-Chartbook-2013.pdf[iv] http://www.lung.org/finding-cures/our-research/trend-reports/copd-trend-report.pdf[v] http://www.lung.org/finding-cures/our-research/trend-reports/copd-trend-report.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, the measure is appropriate for the facility level.
Is the measure currently in use? Yes. Yes: this measure is currently in use in the Hospital Inpatient Quality Reporting Program and the AMA Ethical Force Program’s Patient-Centered Communication Initiative.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? . Yes, the VBP program currently includes 30 day mortality rates for AMI, heart failure, and pneumonia. COPD is also a leading cause of death and hospitalization. This measure is currently used in the IQR program, supporting alignment and parsimony.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: The prevalence of heart failure
(HF) in the United States (U.S.) is high, with 5.2 million Americans currently
diagnosed with this condition (Rosamond et al., 2007). HF incidence increases
with age and approaches 10 per 1000 population after age 65 (Rosamond et al.,
2007). HF is one of the most common causes for hospital admissions among
Medicare beneficiaries (Merrill and Elixhauser, 2005) and hospital discharges
for HF increased 175% from 1979 to 2004 (Rosamond et al., 2007). A recent study
reported that more than 2.5 million Medicare Fee-for-Service (FFS) beneficiaries
were hospitalized for HF during 2001-2005, and more than 1 in 10 Medicare
beneficiaries died within 30 days of hospitalization (Curtis et al., 2008).
Thirty-day HF mortality rates vary considerably across hospitals (Rosenthal et
al., 2000) and hospitals that perform well on the Hospital Quality Alliance
(HQA) performance measures have lower risk-adjusted mortality rates (Jha et al.,
2007). The high prevalence and considerable morbidity and mortality associated
with HF create an economic burden on the healthcare system. In 2005, HF was the
fifth most expensive condition treated in U.S. hospitals, accounting for 3.5% of
the national hospital bill. It was also the second most expensive condition
billed to Medicare that year, accounting for 5.5% of Medicare's hospital bill
(Andrews and Elixhauser, 2007). Many current hospital interventions are known
to decrease the risk of death within 30 days of hospital admission. Current
process-based performance measures, however, cannot capture all the ways that
care within the hospital might influence outcomes. As a result, many
stakeholders, including patient organizations, are interested in outcomes
measures that would permit groups of providers to assess their relative outcomes
performance for the purpose of internal quality improvement or public reporting.
Mortality of patients with HF represents a significant outcome potentially
related to quality of care. This rate-based indicator identifies an undesirable
outcome of care. High rates warrant investigation into the quality of care
provided.
| Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization for program(s): IQR (MUC ID: E0468) |
NQF Number (if applicable): 0468
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: UPDATE TO FINALIZED MEASURE) Pneumonia mortality remains an important area of hospital quality and this expanded measure would reduce coding biases. This high-impact fully specified, tested and endorsed outcome measure is already in use in several public and private programs including IQR. MAP is being asked to consider the implementation of an updated version of the measure.
Does the measure address a critical program objective as defined by MAP? Yes. In the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. – · N/A. This measure is currently in the IQR program measure set. MAP is being asked to consider an updated version of the measure. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia. CMS believes this revised measure would decrease biases in coding. · MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. N/Ao Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. · Yes, the current U.S. national rate for 30-day pneumonia mortality is 11.9%. When evaluating this measure, the NQF Pulmonary and Critical Care Steering Committee noted striking performance variation within and across regions and believed there is further potential for improvement on this measure.[i] Additionally, pneumonia is the second leading cause of hospitalization and the leading cause of death related to infection for patients over 65 years old.[ii] o Move towards more outcome measures rather than structure or process measures. · Yes, this is an outcome measureo Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is currently in the program measure set. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia. CMS believes this revised measure would decrease biases in coding. [i] NQF. Pulmonary and Critical Care Consensus Standards Endorsement Maintenance. 2013. [ii] Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results of a measure of 30-day readmission following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes. Estimated completion date for development (cohort change): February 28, 2015
Is the measure currently in use? Yes. Yes, a prior version of this measure is in use in the Hospital Inpatient Quality Reporting Program, and the Hospital Value-Based Purchasing Program. Additionally this measure is in a number of state and private initiatives, including the Blue Cross Blue Shield MA Alternative Quality Contract, the AmeriHealth Mercy Family of Companies, the Alliance for Health (West Michigan) Publicly Reported Measures, the Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures, the Health Collaborative's Publicly Reported Measures, and the Pennsylvania Health Care Quality Alliance Measures. § The revised version of the measure is under consideration for both VBP and IQR
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsement in 2008. Endorsement was renewed in 2013.
Rationale for measure provided by HHS: Among patients over 65 years of
age, pneumonia is the second leading cause of hospitalization, and is the
leading infectious cause of death (Lindenauer et al., 2011). Many current
hospital interventions are known to decrease the risk of death within 30 days of
hospital admission (Jha et. al., 2007). Current process-based performance
measures, however, cannot capture all the ways that care within the hospital
might influence outcomes. As a result, many stakeholders, including patient
organizations, are interested in outcomes measures that allow patients and
providers to assess relative outcomes performance for hospitals (Bratzler et
al., 2007). References: Bratzler, DW, Nsa W, Houck PM. Performance measures for
pneumonia: are they valuable, and are process measures adequate. Current Opinion
in Infectious Diseases. 20(2):182-189, April 2007. Jha AK, Orav EJ, Li Z,
Epstein AM. The inverse relationship between mortality rates and performance in
the Hospital Quality Alliance measures. Health Aff (Millwood) 2007
Jul-Aug;26(4):1104-10. Lindenauer PK, Normand SL, Drye EE, et al. Development,
validation, and results of a measure of 30-day readmission following
hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
| Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization for program(s): HVBP (MUC ID: E0468) |
NQF Number (if applicable): 0468
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of HVBP, has been tested at the appropriate level of analysis, is NQF endorsed, and supports alignment across programs. In addition,Pneumonia mortality remains an important area of hospital quality and this expanded measure would reduce coding biases.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Program ObjectivesInclude measures where there is a need and opportunity for improvement. Yes- The current U.S. national rate for 30-day pneumonia mortality is 11.9%. When evaluating this measure, the NQF Pulmonary and Critical Care Steering Committee noted striking performance variation within and across regions and believed there is further potential for improvement on this measure.[i] Emphasize areas of critical importance for high performance and quality improvement, and ideally, link clinical quality and cost measures to capture value.Yes, pneumonia is the second leading cause of hospitalization and the leading cause of death related to infection for patients over 65 years old.[ii] NQF-endorsed measures are strongly preferred.Yes, this measure is NQF-endorsed. Keep the program measure set parsimonious to avoid diluting the payment incentives.Yes, this measure is currently in the program measure set. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia. CMS believes this revised measure would decrease biases in coding. MAP identified a number of gap areas that should be addressed within the VBP program measure set, including medication errors, mental and behavioral health, emergency department throughput, a hospital’s culture of safety, and patient and family engagement.N/A-this measure is currently included in the program measure set. MAP is being asked to consider a revised version of the measure. [i] NQF. Pulmonary and Critical Care Consensus Standards Endorsement Maintenance. 2013. [ii] Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results of a measure of 30-day readmission following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes. Estimated completion date for development (cohort change): February 28, 2015
Is the measure currently in use? Yes. Yes, the current version of the measure measure is in use in the Hospital Inpatient Quality Reporting Program, and the Hospital Value-Based Purchasing Program. Additionally this measure is in a number of state and private initiatives, including the Blue Cross Blue Shield MA Alternative Quality Contract, the AmeriHealth Mercy Family of Companies, the Alliance for Health (West Michigan) Publicly Reported Measures, the Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures, the Health Collaborative's Publicly Reported Measures, and the Pennsylvania Health Care Quality Alliance Measures. The revised version of the measure is under consideration for both VBP and IQR.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Among patients over 65 years of
age, pneumonia is the second leading cause of hospitalization, and is the
leading infectious cause of death (Lindenauer et al., 2011). Many current
hospital interventions are known to decrease the risk of death within 30 days of
hospital admission (Jha et. al., 2007). Current process-based performance
measures, however, cannot capture all the ways that care within the hospital
might influence outcomes. As a result, many stakeholders, including patient
organizations, are interested in outcomes measures that allow patients and
providers to assess relative outcomes performance for hospitals (Bratzler et
al., 2007). References: Bratzler, DW, Nsa W, Houck PM. Performance measures for
pneumonia: are they valuable, and are process measures adequate. Current Opinion
in Infectious Diseases. 20(2):182-189, April 2007. Jha AK, Orav EJ, Li Z,
Epstein AM. The inverse relationship between mortality rates and performance in
the Hospital Quality Alliance measures. Health Aff (Millwood) 2007
Jul-Aug;26(4):1104-10. Lindenauer PK, Normand SL, Drye EE, et al. Development,
validation, and results of a measure of 30-day readmission following
hospitalization for pneumonia. J Hosp Med. 2011;6(3):142-150
| Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia hospitalization for program(s): HRRP (MUC ID: E0506) |
NQF Number (if applicable): 0506
Programs under consideration: Hospital Readmission Reduction Program
Preliminary analysis decision: Support
Preliminary analysis summary: UPDATE TO FINALIZED MEASURE) ??This is a patient-care focused measure, addressing pneumonia, a high priority condition, excludes planned and unrelated readmissions and is risk adjusted at the patient-level.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Objectives:Reduce the number of admissions to an acute care hospital within thirty days of a discharge from the same or another acute care hospitalResponse: The measure, endorsed since 2008, addresses the second leading cause of hospitalization for patients over 65 years old. With almost 20% of these hospitalizations resulting in rehospitalization within thirty days, there remains room for improvement in performance on this measure[i]. Specifically, the rate of readmission for pneumonia patients in 17.6%.[ii] This is a revised version of a measure already in the program. A measure of pneumonia readmissions is statutorily mandated for the HRRP program by the Affordable Care Act. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia. CMS believes this revised measure would decrease biases in coding. Improve patient care and reduce overall healthcare costs.Response: Pneumonia results in 1.2 million hospital admissions and for than $10 billion annuals in hospital expenditures. MedPAC estimates that about 8.9% of Medicare patients admitted to the hospital with pneumonia were readmitted within 15 days at a cost of $533 million.[iii] Continued focus should be placed on this outcome since there continues to be a wide range in performance with the median hospital risk-standardized readmission rate (RSRR) for pneumonia was 17.7% with a range of 13.4% to 25.5%. The 5th percentile was 15.7% and the 95th percentile was 20.5%. This distribution in performance represents significant opportunity for improvement in patient care and overall expenditures[iv]Recognize that multiple entities across the health care system, including hospitals, post-acute care facilities, skilled nursing facilities, and others, all have a responsibility to ensure high quality care transitions to reduce unplanned readmissions to the hospital.Response: While this measure only attributes the readmission to the hospital, it does encourage the hospital to work together to improve coordination of care across healthcare facilities and providers.Engage patients and their families as partners in care-Response: This measure would provide information to patients and families that has the potential to engage them as partners in careExclude planned and unrelated readmissions from the measures in the program.Response: Yes, planned and unrelated readmissions are excluded in this measureAcknowledge that factors affecting readmissions may include environmental, community-level, and patient-level factors, including socio-demographic factors.Response: This measure includes patient-level risk adjusters that are predictive of readmissions, based on empirical analysis, prior literature, and clinical judgment, including age and indicators of comorbidity and disease severity.Encourage hospitals to take a leadership role in improving care beyond their walls through care coordination across providers since the causes of readmissions are complex and multifactorial- n/a[i]http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.qualityforum.org%2FWorkArea%2Flinkit.aspx%3FLinkIdentifier%3Did%26ItemID%3D69918&ei=UbVqVPXmFsTLsAS0_oHYAg&usg=AFQjCNG5SxcAaECsZhElXZlhgCqJBC_wow&sig2=Ah7tREX_F7U_whWOYEPR6g&bvm=bv.79908130,d.cWc[ii] https://data.medicare.gov/data/hospital-compare[iii] Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission,2007.[iv]http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.qualityforum.org%2FWorkArea%2Flinkit.aspx%3FLinkIdentifier%3Did%26ItemID%3D69918&ei=UbVqVPXmFsTLsAS0_oHYAg&usg=AFQjCNG5SxcAaECsZhElXZlhgCqJBC_wow&sig2=Ah7tREX_F7U_whWOYEPR6g&bvm=bv.79908130,d.cWc
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the facility level.
Is the measure currently in use? Yes. This measure is already in HRRP. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia. CMS believes this revised measure would decrease biases in coding. The prior version of this measure is used in eValue8, the Alliance for Health (West Michigan) Publicly Reported Measures, Healthy York County Coalition Publicly Reported Measures (South Central PA AF4Q), Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures, Oregon Health Care Quality Corporation Publicly Reported Measures, and the Pennsylvania Health Care Quality Alliance Measures.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. This outcome measure, that is part of the MAP Affordability Family of Measures, contributes to the efficient use of measurement resources and supports alignment across programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsement in 2008. Endorsement was renewed in 2013.
Rationale for measure provided by HHS: The Medicare Payment Advisory
Commission (MedPAC) has called for hospital-specific public reporting of
readmission rates, identifying pneumonia as a priority condition (MedPAC, 2007).
MedPAC finds that readmissions are common, costly, and often preventable. Based
on 2005 Medicare data, MedPAC estimates that about 8.9% of Medicare pneumonia
admissions were followed by a readmission within 15 days, accounting for more
than 74,000 admissions at a cost of $533 million. Pneumonia results in
approximately 1.2 million hospital admissions each year and accounts for more
than $10 billion annually in hospital expenditures. Among patients over 65 years
of age, it is the second leading cause of hospitalization, and is the leading
infectious cause of death (Lindenauer et. al., 2011). Approximately 20% of
pneumonia patients were rehospitalized within thirty days, representing the
second-highest proportion of all rehospitalizations at 6.3% (Jencks 2009).
Pneumonia readmission is a costly event and represents an undesirable outcome of
care from the patient’s perspective, and highly disparate pneumonia readmission
rates among hospitals suggest there is room for improvement. (MedPAC 2007,
Bernheim 2010). References: Bernheim SM, et al. 2010 Measures Maintenance
Technical Report: Acute Myocardial Infarction, Heart Failure and Pneumonia
30-day Risk Standardized Mortality Rate. 2010 Available at:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier3&cid=1163010421830
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28.
Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results
of a measure of 30-day readmission following hospitalization for pneumonia. J
Hosp Med. 2011;6(3):142-150 Report to the Congress: Promoting Greater Efficiency
in Medicare. Washington, DC: Medicare Payment Advisory Commission, 2007.
| Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia hospitalization for program(s): IQR (MUC ID: E0506) |
NQF Number (if applicable): 0506
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: UPDATE TO FINALIZED MEASURE) ?This high-impact fully specified, tested and endorsed outcome measure, which is part of the MAP Safety Family of Measures, is already in use in several public and private programs including IQR. MAP is being asked to consider the implementation of an updated version of the measure.
Does the measure address a critical program objective as defined by MAP? Yes. This patient-care focused measure, that focuses on pneumonia, a high priority condition, excludes planned and unrelated readmissions and is risk adjusted at the patient-level. Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. The measure, endorsed since 2008, addresses the second leading cause of hospitalization for patients over 65 years old.With almost 20% of these hospitalizations resulting in rehospitalization within thirty days, there remains room for improvement in performance on this measure[i]. Specifically, the rate of readmission for pneumonia patients in 17.6%.[ii]Pneumonia results in 1.2 million hospital admissions and for than $10 billion annuals in hospital expenditures. MedPAC estimates that about 8.9% of Medicare patients admitted to the hospital with pneumonia were readmitted within 15 days at a cost of $533 million.[iii] Continued focus should be placed on this outcome since there continues to be a wide range in performance with the median hospital risk-standardized readmission rate (RSRR) for pneumonia was 17.7% with a range of 13.4% to 25.5%. The 5th percentile was 15.7% and the 95th percentile was 20.5%. This distribution in performance represents significant opportunity for improvement in patient care and overall expenditures[iv].This is a revised version of a measure already in the program. MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia.CMS believes this revised measure would decrease biases in coding.Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measure. Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is included in the Hospital Readmissions Reduction ProgramIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. N/AN/A.This measure is currently in the IQR program measure set.MAP is being asked to consider an updated version of the measure. [i]http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.qualityforum.org%2FWorkArea%2Flinkit.aspx%3FLinkIdentifier%3Did%26ItemID%3D69918&ei=UbVqVPXmFsTLsAS0_oHYAg&usg=AFQjCNG5SxcAaECsZhElXZlhgCqJBC_wow&sig2=Ah7tREX_F7U_whWOYEPR6g&bvm=bv.79908130,d.cWc[ii] https://data.medicare.gov/data/hospital-compare[iii] Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission,2007.[iv]http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.qualityforum.org%2FWorkArea%2Flinkit.aspx%3FLinkIdentifier%3Did%26ItemID%3D69918&ei=UbVqVPXmFsTLsAS0_oHYAg&usg=AFQjCNG5SxcAaECsZhElXZlhgCqJBC_wow&sig2=Ah7tREX_F7U_whWOYEPR6g&bvm=bv.79908130,d.cWc
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes. Estimated completion date for development (cohort change): February 28, 2015
Is the measure currently in use? Yes. This measure is already in IQR.MAP is being asked to consider a revised version of the measure that would expand the cohort of patients included in the measure to include patients with a primary diagnosis of aspiration pneumonia.CMS believes this revised measure would decrease biases in coding.The prior version of this measure is used in eValue8, the Alliance for Health (West Michigan) Publicly Reported Measures, Healthy York County Coalition Publicly Reported Measures (South Central PA AF4Q), Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures, Oregon Health Care Quality Corporation Publicly Reported Measures, and the Pennsylvania Health Care Quality Alliance Measures.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsement in 2008. Endorsement was renewed in 2013.
Rationale for measure provided by HHS: The Medicare Payment Advisory
Commission (MedPAC) has called for hospital-specific public reporting of
readmission rates, identifying pneumonia as a priority condition (MedPAC, 2007).
MedPAC finds that readmissions are common, costly, and often preventable. Based
on 2005 Medicare data, MedPAC estimates that about 8.9% of Medicare pneumonia
admissions were followed by a readmission within 15 days, accounting for more
than 74,000 admissions at a cost of $533 million. Pneumonia results in
approximately 1.2 million hospital admissions each year and accounts for more
than $10 billion annually in hospital expenditures. Among patients over 65 years
of age, it is the second leading cause of hospitalization, and is the leading
infectious cause of death (Lindenauer et. al., 2011). Approximately 20% of
pneumonia patients were rehospitalized within thirty days, representing the
second-highest proportion of all rehospitalizations at 6.3% (Jencks 2009).
Pneumonia readmission is a costly event and represents an undesirable outcome of
care from the patient’s perspective, and highly disparate pneumonia readmission
rates among hospitals suggest there is room for improvement. (MedPAC 2007,
Bernheim 2010). References: Bernheim SM, et al. 2010 Measures Maintenance
Technical Report: Acute Myocardial Infarction, Heart Failure and Pneumonia
30-day Risk Standardized Mortality Rate. 2010 Available at:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier3&cid=1163010421830
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28.
Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results
of a measure of 30-day readmission following hospitalization for pneumonia. J
Hosp Med. 2011;6(3):142-150 Report to the Congress: Promoting Greater Efficiency
in Medicare. Washington, DC: Medicare Payment Advisory Commission, 2007.
| Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following acute myocardial infarction (AMI) hospitalization for program(s): IQR (MUC ID: X3728) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This measure would help address a concern noted by the NQF Admissions/Readmissions Standing Committee that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates. ?
Does the measure address a critical program objective as defined by MAP? Yes. This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, any need to return to an acute care setting is impactful to a patient’s quality of life. Additionally, there is evidence that keeping patients in observation status have negative financial and quality of life impacts on patients.[i]Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.N/AEngage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses care coordination as readmissions can be seen as the ultimate failure in care coordination. This measure would address any return by a patient to an acute care setting including observation stays and emergency department visits. ED visits are a substantial portion of post-discharge acute care use. Studies have shown that 9.5% of patients return to the ED within 30 days of discharge and around 12% are discharged from the ED without being readmitted and would therefore not be included in the current readmission measure in IQR.[ii],[iii] Additionally, the use of observation stays has risen dramatically-from 2001-2008 there was a three-fold increase in the observation status.[iv] The Office of the Inspector General found that Medicare beneficiaries have 1.5 million observation stays annually. [i] http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2013/rapid-growth-in-medicare-hospital-observation-services-AARP-ppi-health.pdf [ii] Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine. [iii] Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364-371. [iv] Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No. This measure is in beta testing. This measure is still in development.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure would help address a concern noted by the NQF Admissions/Readmissions Standing Committee that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates. This rise in use is an important quality problem and this measure would close a potential gap in improvement by looking at observation stays and ED visits in addition to readmissions.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: The goal of this measure is to
improve patient outcomes by providing patients, physicians, and hospitals with
information about hospital-level, risk-standardized outcomes following
hospitalization for AMI. Measurement of patient outcomes allows for a broad view
of quality of care that cannot be captured entirely by individual
process-of-care measures. Safely transitioning patients from hospital to home
requires a complex series of tasks which would be cumbersome to capture
individually as process measures: timely and effective communication between
providers, prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and emergency
department evaluation. There already exist measures for readmission, but there
are no current measures for ED utilization and observation stay. It is thus
difficult for providers and consumers to gain a complete picture of
post-discharge outcomes. Moreover, separately reporting each outcome encourages
“gaming,” such as recategorizing readmission stays as observation stays to avoid
a readmission outcome. By constructing a composite of outcomes that are
important to patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and incentivizes
global improvement in outcomes. Acute myocardial infarction (AMI) is among the
most common principal hospital discharge diagnoses among Medicare beneficiaries,
and, in 2008, it was the sixth most expensive condition billed to Medicare,
accounting for 4.8% of Medicare’s hospital bill (Wier and Andrews, 2011).
Readmission rates following discharge for AMI are high. For example, between
July 2005 and June 2008, the median 30-day readmission rate for AMI was 19.9%,
with a range of 15.3% to 29.4% (Krumholz et al., 2009). Acute care utilization
after discharge (return to the emergency department, observation stay and
readmission), for any reason, is disruptive to patients and caregivers, costly
to the healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some readmissions are
unavoidable, they may also result from poor quality of care or inadequate
transitional care. Transitional care includes effective discharge planning,
transfer of information at the time of discharge, patient assessment and
education, and coordination of care and monitoring in the post-discharge period.
Numerous studies have found an association between quality of inpatient or
transitional care and early (typically 30-day) readmission rates for a wide
range of conditions including AMI (Frankl et al., 1991; Corrigan et al., 1992;
Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et
al., 2003; Halfon et al., 2006; Bondestam et al., 1995; Carlhed et al., 2009).
Several studies have reported on the relationship between inpatient admissions
and other types of hospital care including ED visits and observation stays. ED
visits represent a significant proportion of post-discharge acute care
utilization. Two recent studies conducted in patients of all ages have shown
that 9.5% of patients return to the ED within 30 days of hospital discharge and
that about 12% of these patients are discharged from the ED and are not captured
by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013).
Additionally, over the past decade, the use of observation stays has rapidly
increased. Specifically, between 2001 and 2008, the use of observation services
increased nearly three-fold (Venkatesh et al., 2011) and significant variation
has been demonstrated in the use of observation services for conditions such as
chest pain (Schuur et al., 2011). These rising rates of observation stays among
Medicare beneficiaries have gained the attention of
| Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following heart failure hospitalization for program(s): IQR (MUC ID: X3722) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This measure would help address a concern noted by the NQF Admissions/Readmissions Standing Committee that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates for a high impact condition.
Does the measure address a critical program objective as defined by MAP? Yes. This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, any need to return to an acute care setting is impactful to a patient’s quality of life. Additionally, there is evidence that keeping patients in observation status have negative financial and quality of life impacts on patients.[i]Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.N/AEngage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses care coordination as readmissions can be seen as the ultimate failure in care coordination. This measure would address any return by a patient to an acute care setting including observation stays and emergency department visits. ED visits are a substantial portion of post-discharge acute care use. Studies have shown that 9.5% of patients return to the ED within 30 days of discharge and around 12% are discharged from the ED without being readmitted and would therefore not be included in the current readmission measure in IQR.[ii],[iii] Additionally, the use of observation stays has risen dramatically-from 2001-2008 there was a three-fold increase in the observation status.[iv] The Office of the Inspector General found that Medicare beneficiaries have 1.5 million observation stays annually. [i] http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2013/rapid-growth-in-medicare-hospital-observation-services-AARP-ppi-health.pdf [ii] Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine. [iii] Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364-371. [iv] Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No. This measure is in beta testing.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure would help address a concern noted by the NQF Admissions/Readmissions Standing Committee that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates. This rise in use is an important quality problem and this measure would close a potential gap in improvement by looking at observation stays and ED visits in addition to readmissions.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: The goal of this measure is to
improve patient outcomes by providing patients, physicians, and hospitals with
information about hospital-level, risk-standardized outcomes following
hospitalization for heart failure. Measurement of patient outcomes allows for a
broad view of quality of care that cannot be captured entirely by individual
process-of-care measures. Safely transitioning patients from hospital to home
requires a complex series of tasks which would be cumbersome to capture
individually as process measures: timely and effective communication between
providers, prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and emergency
department evaluation. There already exist measures for readmission, but there
are no current measures for ED utilization and observation stay. It is thus
difficult for providers and consumers to gain a complete picture of
post-discharge outcomes. Moreover, separately reporting each outcome encourages
“gaming,” such as recategorizing readmission stays as observation stays to avoid
a readmission outcome. By constructing a composite of outcomes that are
important to patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and incentivizes
global improvement in outcomes. Heart failure is the most common principal
discharge diagnosis among older adults and the third highest for hospital
reimbursements in 2005 (CMS, 2006) and the leading cause of death and
readmission among Medicare beneficiaries, with nearly half of heart failure
patients expected to return to the hospital within six months of discharge
(Jencks et al., 2009; Krumholz et al., 1997; Lloyd-Jones et al., 2010).
Readmission rates following discharge for heart failure are high and variable
across hospitals in the United States (Krumholz et al., 2009; Bernheim et al.,
2010). For example, for the time period of July 2011-June 2012, publicly
reported 30-day risk-standardized readmission rates ranged from 17.5% to 30.3%
for patients admitted with heart failure (CMS, 2013) Acute care utilization
after discharge (return to the emergency department, observation stay and
readmission), for any reason, is disruptive to patients and caregivers, costly
to the healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some readmissions are
unavoidable, they may also result from poor quality of care or inadequate
transitional care. Transitional care includes effective discharge planning,
transfer of information at the time of discharge, patient assessment and
education, and coordination of care and monitoring in the post-discharge period.
Numerous studies have found an association between quality of inpatient or
transitional care and early (typically 30-day) readmission rates for a wide
range of conditions including heart failure (Frankl et al., 1991; Corrigan et
al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000;
Courtney et al., 2003; Halfon et al., 2006; Hernandez et al., 2010). Several
studies also have reported on the relationship between inpatient admissions and
other types of hospital care including ED visits and observation stays. ED
visits represent a significant proportion of post-discharge acute care
utilization. Two recent studies conducted in patients of all ages have shown
that 9.5% of patients return to the ED within 30 days of hospital discharge and
that about 12% of these patients are discharged from the ED and are not captured
by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013).
Additionally, over the past decade, the use of observation stays has rapidly
increased. Specifically, between 2001 and 2008, the use of observation services
incre
| Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization for program(s): IQR (MUC ID: X3727) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This measure would help address a concern that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates for this high impact condition.
Does the measure address a critical program objective as defined by MAP? Yes. This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, any need to return to an acute care setting is impactful to a patient’s quality of life. Additionally, there is evidence that keeping patients in observation status have negative financial and quality of life impacts on patients.[i]Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.N/AEngage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses care coordination as readmissions can be seen as the ultimate failure in care coordination. This measure would address any return by a patient to an acute care setting including observation stays and emergency department visits. ED visits are a substantial portion of post-discharge acute care use. Studies have shown that 9.5% of patients return to the ED within 30 days of discharge and around 12% are discharged from the ED without being readmitted and would therefore not be included in the current readmission measure in IQR.[ii],[iii] Additionally, the use of observation stays has risen dramatically-from 2001-2008 there was a three-fold increase in the observation status.[iv] The Office of the Inspector General found that Medicare beneficiaries have 1.5 million observation stays annually. [i] http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2013/rapid-growth-in-medicare-hospital-observation-services-AARP-ppi-health.pdf [ii] Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine. [iii] Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364-371. [iv] Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No. This measure is in beta testing.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure would help address a concern noted by the NQF Admissions/Readmissions Standing Committee that observation stays and ED visits may be increasing as a result of an increased focus on readmission rates. This rise in use is an important quality problem and this measure would close a potential gap in improvement by looking at observation stays and ED visits in addition to readmissions.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: The goal of this measure is to
improve patient outcomes by providing patients, physicians, and hospitals with
information about hospital-level, risk-standardized outcomes following
hospitalization for pneumonia. Measurement of patient outcomes allows for a
broad view of quality of care that cannot be captured entirely by individual
process-of-care measures. Safely transitioning patients from hospital to home
requires a complex series of tasks which would be cumbersome to capture
individually as process measures: timely and effective communication between
providers, prevention of and response to complications, patient education about
post-discharge care and self-management, and timely follow-up, and more.
Inadequate transitional care contributes to a variety of adverse outcomes
post-discharge, including readmission, need for observation, and emergency
department evaluation. There already exist measures for readmission, but there
are no current measures for ED utilization and observation stay. It is thus
difficult for providers and consumers to gain a complete picture of
post-discharge outcomes. Moreover, separately reporting each outcome encourages
“gaming,” such as recategorizing readmission stays as observation stays to avoid
a readmission outcome. By constructing a composite of outcomes that are
important to patients, we can produce a more complete picture of post-discharge
outcomes that better informs consumers about care quality and incentivizes
global improvement in outcomes. Pneumonia results in approximately 1.2 million
hospital admissions each year and accounts for more than $10 billion annually in
hospital expenditures. Among patients over 65 years of age, it is the second
leading cause of hospitalization, and is the leading infectious cause of death
(Lindenauer et al., 2011). Approximately 20% of pneumonia patients were
rehospitalized within thirty days, representing the second-highest proportion of
all rehospitalizations at 6.3% (Jencks et al., 2009). Acute care utilization
after discharge (return to the emergency department, observation stay and
readmission), for any reason, is disruptive to patients and caregivers, costly
to the healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some readmissions are
unavoidable, they may also result from poor quality of care or inadequate
transitional care. Transitional care includes effective discharge planning,
transfer of information at the time of discharge, patient assessment and
education, and coordination of care and monitoring in the post-discharge period.
Numerous studies have found an association between quality of inpatient or
transitional care and early (typically 30-day) readmission rates for a wide
range of conditions including pneumonia (Frankl et al., 1991; Corrigan et al.,
1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney
et al., 2003; Halfon et al., 2006; Dean et al., 2006). Several studies also
have reported on the relationship between inpatient admissions and other types
of hospital care including ED visits and observation stays. ED visits represent
a significant proportion of post-discharge acute care utilization. Two recent
studies conducted in patients of all ages have shown that 9.5% of patients
return to the ED within 30 days of hospital discharge and that about 12% of
these patients are discharged from the ED and are not captured by current CMS
readmissions measures (Rising et al., 2013; Vashi et al., 2013). Additionally,
over the past decade, the use of observation stays has rapidly increased.
Specifically, between 2001 and 2008, the use of observation services increased
nearly three-fold (Venkatesh et al., 2011) and significant variation has been
demonstrated in the use of observation services for conditions such as chest
pain (Schuur et al., 2011). These rising rates of observation stays among
Medicare beneficiaries have gained the attention of patients
| Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) for program(s): IQR (MUC ID: X3620) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This measure could compete with measures X0352 Knee Replacement/Revision Clinical Episode-Based Payment Measure and X03562 Hip Replacement/Revision Clinical Episode-Based Payment Measure. MAP would encourage a timely review of these measures by the NQF Cost and Resource Use Standing Committee to resolve this potential issue. MAP would encourage the most parsimonious approach to measuring the costs of hip and knee replacements to minimize the burden and confusion of competing methodologies.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Objectives: Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Yes, over 33% of Americans 65 and older suffer from osteoarthritis. [i] Joint replacement surgeries are becoming more commonly utilized as Medicare covered 337,419 THA procedures and 750,569 TKA procedures between 2009 and 2012 [ii] and annual Medicare payments for THA and TKA exceed $15 billion annually.[iii] There is significant variation in costs for these procedures that are often related to quality of care as complications and readmissions increase the total payment for post-surgical care.[iv]Move towards more outcome measures rather than structure or process measures. Yes, this is an outcome measure Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. N/AEngage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate. N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses cost for two common inpatient surgical procedures. [i] Centers for Disease Control and Prevention (CDC). Osteoarthritis. 2011; http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed August 13, 2013.[ii] Suter LG, Grady JN, Lin Z, et al. 2013 Measure Updates and Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or Total Knee Arthroplasty (TKA) All-Cause Unplanned 30-Day Risk-Standardized Readmission Measure (Version 2.0). March 2013.[iii] Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health affairs (Project Hope). Nov 2011;30(11):2107-2115.[iv] Suter LG, et al., Medicare Hospital Quality Chartbook 2013: Performance Report on Outcome Measures, 2013.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? Yes. Estimated completion date for development: December 31, 2014This measure has been tested at the facility level.
Is the measure currently in use? No. No, this measure is not currently in use
Does the measure promote alignment and parsimony? Yes. Yes, this measure could help to address the variation in costs in two common hospital procedures.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Due to their frequency and
cost, THA and TKA are priority areas for outcome measure development. More than
one third of the US population 65 years and older suffers from osteoarthritis
[1]. Between 2009 and 2012, there were 337,419 THA procedures and 750,569 TKA
procedures for Medicare fee-for-service patients 65 years and older [2].
Estimates place the annual insurer cost of osteoarthritis in the US at $149
billion, with Medicare direct payments to hospitals for THA/TKA exceeding $15
billion annually [3]. Further, there are conflicting data regarding costs after
total joint arthroplasty, with evidence to support both increased [4] and
decreased costs [5] following arthroplasty, suggesting there is great variation
in the costs of a full episode of care for THA and TKA. Clinical outcomes for
THA and TKA depend not only on the surgeon performing the procedure, but on care
coordination across provider groups and specialties, and the patient’s
engagement in his or her recovery. Even the very best surgeon will not get
outstanding results if there are gaps in the quality of care for the patient
before, during, and after surgery. The goal of hospital-level resource use
measurement is to capture the full spectrum of care in order to incentivize
collaboration and shared responsibility for improving patients’ health and
reducing the burden of their disease. Variation in the cost of a THA or TKA
episode of care is often related to the quality of care, where complications and
readmissions increase the total payment for post-surgical care. Given the
well-documented variation in readmission and complication rates following THA
and TKA, there is expected variation in total episode of care costs for the
procedures [6]. Birkmeyer et al. found that the average 30-day cost increased by
$2,436 among hospitals with the highest quintile of complication rates, compared
to the lowest quintile following THA [7]. The same study also found that
rehabilitation costs accounted for 50% of “excess” payments among those
undergoing THA. Miller et al. found that a major driver of differences in
episode payments for THA was that hospitals within Accountable Care
Organizations (ACO) had smaller payments for post-discharge care compared to
non-ACO hospitals [8]. Taken together, these studies suggest that much of the
variation in total episode costs arises in the post-acute setting. Health
systems have taken notice of opportunities to improve value by encouraging
collaboration of care between hospitals and post-acute providers. The Centers
for Medicare & Medicaid Services’ (CMS’s) Bundled Payment for Care
Improvement initiative aims to assess the feasibility and effectiveness of
various models of bundled payments [9]. One analysis of hospitals found that the
overall episode of care, particularly post-discharge care, was less expensive in
hospitals affiliated with Integrated Delivery Systems [10]. Transparency
regarding the variation of episode of care payments triggered by THA and TKA
helps to guide health systems and providers towards improvement in the value of
care. 1. Centers for Disease Control and Prevention (CDC). Osteoarthritis.
2011; http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed August
13, 2013. 2. Suter LG, Grady JN, Lin Z, et al. 2013 Measure Updates and
Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or Total Knee
Arthroplasty (TKA) All-Cause Unplanned 30-Day Risk-Standardized Readmission
Measure (Version 2.0). March 2013. 3. Miller DC, Gust C, Dimick JB, Birkmeyer
N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery
highlight savings potential from bundled payment programs. Health affairs
(Project Hope). Nov 2011;30(11):2107-2115. 4. Bozic KJ, Stacey B, Berger A,
Sadosky A, Oster G. Resource utilization and costs before and after total joint
arthroplasty. BMC health services research. 2012;12:73. 5. Hawker GA, Badley
EM, Croxford R, et al. A population-based nested case-control stud
| Hospital-Wide All-Cause Unplanned Readmission Hybrid eMeasure for program(s): IQR (MUC ID: X3701) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: While the claims version of this measure is NQF-endorsed (1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)) is already a part of the Hospital Inpatient Quality Reporting, the e-Measure version of this measure is in alpha testing.
Does the measure address a critical program objective as defined by MAP? . This is a high impact measure that is also under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals. The claims version of this care transition outcome measure is already a part of the Hospital Inpatient Quality Reporting. The different data sources would need to be aligned before implementation. Critical Objectives: Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. This is a high impact measure – building on NQF #1789, Hospital-Wide All-Cause Unplanned Readmission Measure but using EHRs as the data source.Move towards more outcome measures rather than structure or process measures. Outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. Under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals; This measure would need to align with measure #1789 currently in the IQR program.Engage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. This measure fills an important gap in care transitions
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. While the claims version of this measure is NQF-endorsed (1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)), the e-Measure version of this measure is in alpha testing and has not been reviewed as an e-Measure for endorsement.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As outcome measure that is also under review for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program that fills the MAP identified priority gap of care transitions, this measure contributes to the efficient use of measurement resources.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Currently, the Centers for
Medicare & Medicaid Services (CMS) publicly reports risk-standardized
readmission rates (RSRRs) for several conditions, including acute myocardial
infarction (AMI), heart failure (HF), pneumonia, and hip and knee arthroplasty.
CMS has also developed hospital readmission measures for stroke and chronic
obstructive pulmonary disease (COPD). While it is helpful to assess readmission
rates for specific groups of patients, these conditions account for only a small
proportion of total readmissions. In 2013, CMS began publicly reporting a
hospital-wide, all-condition readmission measure which provides a broader
assessment of the quality of care at hospitals. This measure, which uses the
same cohort and outcome definitions as the proposed eMeasure, includes 93% of
admissions to acute care non-federal hospitals of Medicare Fee-for-Service
patients over age 65 who are discharged alive to the non-acute care setting. The
measure captures 92% of readmissions following eligible admissions. The
proposed measure will build on the hospital-wide readmission measure by using
clinical data elements derived from electronic health records (EHR), such as
laboratory test values and vital signs, to risk adjust for patient-level factors
that influence readmission. The proliferation of EHR systems and standardization
of extraction and reporting of clinical data for quality measurement provide an
opportunity to integrate these data into measures of hospital performance. This
effort is also responsive to the preference expressed by the clinical community
for the use of clinical data to adjust for patients’ severity of illness in
hospital outcome measures.
| Hospital-Wide All-Cause Unplanned Readmission Hybrid eMeasure for program(s): MUHCAH (MUC ID: X3701) |
NQF Number (if applicable):
Programs under consideration: Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs)
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: While the claims version of this outcome measure isNQF-endorsed (1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)), the e-Measure version of this measure is in alpha testing and has not been reviewed as an e-Measure for endorsement.
Does the measure address a critical program objective as defined by MAP? Yes. Thishigh impactEHR version of theNQF-endorsed claims measure1789, Hospital-Wide All-Cause Unplanned Readmission Measure,is also under review for the Hospital Inpatient Quality Reporting program.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. In alpha testing
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an outcome measure that is also under review for the Hospital Inpatient Quality Reporting program, this measure contributes to the efficient use of measurement resources.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. While the claims version of this measure isNQF-endorsed (1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)), the e-Measure version of this measure is in alpha testing and has not been reviewed as an e-Measure for endorsement.
Rationale for measure provided by HHS: Currently, the Centers for
Medicare & Medicaid Services (CMS) publicly reports risk-standardized
readmission rates (RSRRs) for several conditions, including acute myocardial
infarction (AMI), heart failure (HF), pneumonia, and hip and knee arthroplasty.
CMS has also developed hospital readmission measures for stroke and chronic
obstructive pulmonary disease (COPD). While it is helpful to assess readmission
rates for specific groups of patients, these conditions account for only a small
proportion of total readmissions. In 2013, CMS began publicly reporting a
hospital-wide, all-condition readmission measure which provides a broader
assessment of the quality of care at hospitals. This measure, which uses the
same cohort and outcome definitions as the proposed eMeasure, includes 93% of
admissions to acute care non-federal hospitals of Medicare Fee-for-Service
patients over age 65 who are discharged alive to the non-acute care setting. The
measure captures 92% of readmissions following eligible admissions. The
proposed measure will build on the hospital-wide readmission measure by using
clinical data elements derived from electronic health records (EHR), such as
laboratory test values and vital signs, to risk adjust for patient-level factors
that influence readmission. The proliferation of EHR systems and standardization
of extraction and reporting of clinical data for quality measurement provide an
opportunity to integrate these data into measures of hospital performance. This
effort is also responsive to the preference expressed by the clinical community
for the use of clinical data to adjust for patients’ severity of illness in
hospital outcome measures.
| Influenza Immunization for program(s): PCHQR (MUC ID: E1659) |
NQF Number (if applicable): 1659
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Yes. In its Performance Measurement Coordination Strategy for PPS-Exempt Cancer Hospitals MAP identified safety as a priority area. In past pre-rulemaking decisions, MAP has supported this measure for acute care settings noting the importance of preventing influenza infections among patients and the current variation in performance.[i] The CDC recommends that people with cancer receive a vaccination for influenza annually[ii] as cancer may increase a person’s risk for complications.[iii] Additionally, in 2010, the United States Advisory Committee on Immunization Practices (ACIP) updated their guidelines to recommend influenza vaccines for everyone ages 6 months and older.[iv]Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant.Yes. This measure is currently in the Inpatient Quality Reporting Program measure set.The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this program[i] NQF. MAP Pre-Rulemaking Report: 2013 Recommendations on Measures Under Consideration by HHS.[ii] http://www.preventcancerinfections.org/health-tip-sheet/vaccinations-and-flu?qt-view__health_tip_sheets_slider__block=1#qt-view__health_tip_sheets_slider__block[iii] http://www.cdc.gov/cancer/flu/index.htm[iv] 2014 UptoDate. Seasonal influenza vaccination in adults.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, it is tested and being used in the hospital setting.
Is the measure currently in use? Yes. Yes, it is being used in the Inpatient Quality Reporting Program and Hospital Value-Based Purchasing. Additionally this measure is used by the Pennsylvania Health Care Quality Alliance.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is not duplicative of an existing measure in the PCHQR program. This measure has been identified as a Disparities-sensitive measure and it is part of the MAP Dual Eligible Beneficiaries Family of Measures and the Population Health Family of Measures. Additionally, Hospital Compare shows a national average of 90% on this measure, indicating less than optimal performance and potential for improvement.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #1659.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: Fill a measure gap in program
and alignment of measures. Up to 1 in 5 people in the United States get
influenza every season (CDC, Key Facts). 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
WW, JAMA). Combined with pneumonia, influenza is the nation’s 8th leading cause
of death (Minino, 2004 National Center for Health Statistics). 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). 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 (CDC Press Release February 24,
2010). 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.
| Influenza vaccination coverage among healthcare personnel (HCP) for program(s): PCHQR (MUC ID: E0431) |
NQF Number (if applicable): 0431
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Yes. In its Performance Measurement Coordination Strategy for PPS-Exempt Cancer Hospitals MAP identified safety as a priority area. In its Safety Family of Measures, MAP noted the importance of influenza vaccination among healthcare workers as a way to reduce healthcare-associated infections. Additionally, the CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that healthcare workers receive an influenza vaccination annually.[i] Flu vaccination coverage among healthcare personnel was approximately 75% overall but was almost 98% in settings with vaccination requirements[ii]. Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant. Yes, this measure is currently in the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program measure sets. The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this program.No, this measure does not address a previously identified gap.[i] http://www.cdc.gov/flu/healthcareworkers.htm[ii] http://www.cdc.gov/flu/healthcareworkers.htm
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, it is tested and being used in the hospital setting.
Is the measure currently in use? Yes. Yes, it is being used in the Ambulatory Surgical Center Quality Reporting Program, the Hospital Inpatient Quality Reporting Program, the Inpatient Rehabilitation Facilities Quality Reporting Program, and the Long-term Care Hospital Quality Reporting Program. This measure is also included in Joint Commission accreditation programs.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is not duplicative of an existing measure in the PCHQR program. This measure would promote alignment between programs assessing general acute care and cancer hospitals (IQR and PCHQR).
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #0431.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: Fill gap in program and for
measure alignment across programs Use of this measure to monitor influenza
vaccination among HCP is envisioned to result in increased influenza vaccination
uptake among HCP, because improvements in tracking and reporting HCP influenza
vaccination status will allow healthcare institutions to better identify and
target unvaccinated HCP. Increased influenza vaccination coverage among HCP is
expected to result in reduced morbidity and mortality related to influenza virus
infection among patients. 1. Hayward AC, Harling R, Wetten S, et al.
Effectiveness of an influenza vaccine programme for care home staff to prevent
death, morbidity, and health service use among residents: cluster randomized
controlled trial. BMJ 2006; 333: 1241-1246. 2. Potter J, Stott DJ, Roberts MA,
et al. Influenza vaccination of healthcare workers in long-term-care hospitals
reduces the mortality of elderly patients. J Infect Dis. 1997; 175:1-6. 3.
Lemaitre M, Meret T, Rothan-Tondeur M, et al. Effect of influenza vaccination of
nursing home staff on mortality of residents: a cluster-randomized trial. J Am
Geriatr Soc. 2009; 57:1580-1586. 4. Carman WF, Elder AG, Wallace LA, et al.
Effects of influenza vaccination of health-care workers on mortality of elderly
people in long-term care: a randomized controlled trial. Lancet 2000; 355:93–97.
5. Talbot TR, Babcock H, Caplan AL, et al. Revised SHEA position paper:
influenza vaccination of healthcare personnel. Infection Control and Hospital
Epidemiology 2010; 31:987-995.
| In-hospital mortality following elective open repair of AAAs for program(s): MSSP (MUC ID: E1523) |
NQF Number (if applicable): 1523
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure represents an important cardiac outcome for a large number of Medicare beneficiaries. This measure is currently used by private sector registries, and is undery consideration for the other PQRS-based programs. While the measure does not address care across settings, and providers, it does represent an important opportunity for quality improvement in the Medicare FFS population.
Does the measure address a critical program objective as defined by MAP? Yes. Yes, this measure would address an important outcome for patients with a common cardiac condition. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure focuses on an important cardiovascular outcome for Medicare Fee-for-Service beneficiaries[i]. Given that ruptured AAAs are the 15th leading cause of death overall in the United States, and the 10th leading cause of death in males over 55 years – it represents and important area of measurement for Medicare[ii].· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure does not directly address the rate of growth of healthcare spending.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not span multiple care settings.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: Yes. This measure is currently in use in the Vascular Study Group of New England Registry private program, but not in any federal programs. It is under consideration for use in PQRS-based programs, including Physician Compare, Physician Feedback/Quality and Resource utilization Reports, and Physician Value Based Payment Modifier Program. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: While this measure addresses an important cardiac quality endpoint, it does not address the high-value areas identified by MAP for this program.[i] http://www.qualityforum.org/Publications/2012/06/Surgery_Endorsement_Maintenance_2010_Technical_Report.aspx[ii] Fillinger M. (2010) Abdominal Aortic Aneurysms: Evaluation and Decision Making. In J. Cronenewett &KW. Johnston (Eds.), Rutherford´s Vascular Surgery (1928-1948) Saunders Elsevier. Philadelphia.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is currently used at least one private program (Vascular Study Group of New England registry) and is under review for multiple programs (Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, and Physician Value-Based Payment Modifier Program)
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is under consideration for multiple federal programs, applies to abroad population (all payers), and uses registries as a data source. It also aligns with the NQS priority of making care safer by reducing harm caused in the delivery of care.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Elective repair of a small or
moderate sized AAA is a prophylactic procedure and the mortality/morbidity of
the procedure must be contrasted with the risk of rupture over time. Surgeons
should select patients for intervention who have a reasonable life expectancy
and who do not have a high surgical risk.
| Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0351) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0351) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional Support pending NQF review and endorsement
Preliminary analysis summary: This measure addresses the cost of care for a common condition. UTIs are mainly treated on an outpatient basis but the cost of care can be high if hospitalization and follow-up is required.
Does the measure address a critical program objective as defined by MAP? Yes. Response: This measure addresses the cost of care for a common condition. UTIs are mainly treated on an outpatient basis but the cost of care can be high if hospitalization and follow-up is required.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, the costs of treatment can be high if a patient is hospitalized for a UTI. While urinary tract infections are primarily treated in an outpatient setting, they can lead to complications and costly hospitalizations and follow-up care. Urinary tract infections (UTIs) are the second most common type of infection however; vast the majority of these infections are treated in an outpatient setting, not in a hospital. UTIs are responsible for approximately eight million visits to health care providers annually and about 200,000 of those results in hospitalization. Move towards more outcome measures rather than structure or process measures.N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. ?Yes, this measure addresses cost.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure could help to address the variation in costs in a common condition.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Knee Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0352) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Knee Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0352) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Medication Information for program(s): OQR (MUC ID: E0293) |
NQF Number (if applicable): 0293
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set, which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the medication information, which includes information on the medication history, allergies, and medications given (MAR) was communicated to the receiving facility within 60 minutes of departure.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module. Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patient safety studies have
identified the Emergency Department as the location within a hospital that has
the highest percentage of preventable and negligent adverse events.1-2
Increasing attention is being paid to prevention of medical errors in Emergency
Department settings, but considerable work still needs to be done to develop
performance measures for Emergency Department care.3-4 Patients who are
transferred from an Emergency Department to another facility are excluded from
the calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other facilities than do larger urban facilities.5-9 1. Leape, L.,
Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized
Patients. Results of the Harvard Medical Practice Study II. New England Journal
of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D., Burstin, H. et al.
Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado.
Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting Patient Safety and
Preventing Medical Error in Emergency Departments. Academic Emergency Medicine
7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C. and Reese, C.
Emergency Department Performance Measures and Benchmarking Summit. Academic
Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell KJ, Hedges
JR. Variability of trauma transfer practices among non-tertiary care hospital
emergency departments. . Academic Emergency Medicine 13:746-754, 2006. 6.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
hospitals in Kansas. Journal of Rural Health. 20:363-367, 2004. 8. Baldwin LM,
MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in
rural and urban US hospitals. Journal of Rural Health, 20:99-108, 2004. 9.
Westfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest
pain in rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at: http://www.jointcommission.org/SentinelEvents
/Statistics/. Accessed July 18, 2007. 11. Kripalani, S., LeFevre, F., Phillips,
C. et al. Deficits in Communication and Information Transfer between
Hospital-Based and Primary Care Physicians: Implications for Patient Safety and
Continuity of Care. JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and
Fitzpatrick J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004. 13. Joint Commission on Accreditation of Healthcare
Organizations. 2008 National Patient Safety Goals. Available at:
http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18, 2007.
| MRI Lumbar Spine for Low Back Pain for program(s): MSSP (MUC ID: E0514) |
NQF Number (if applicable): 0514
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending resubmission to NQF for endorsement review.
Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a high impact area of healthcare including improving overall health and reducing the growth of healthcare spending. The Musculoskeletal Standing Comymittee noted that MRI lumbar spine studies without antecedent conservative therapy can contribute to poor patient outcomes and a higher cost of care.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Low back pain is very prevalent in Medicare patients. Advanced imaging overuse contributes to higher rate of spending without improvement in outcomes· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: Yes.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not measure care that spans providers or care settings. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: Yes. This measure is currently in use in federal and private programs including the Hospital Outpatient Quality Reporting program and the URAC Health Plan with Health Insurance Exchange. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure addresses appropriate use of imaging.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is currently in use in both federal (Hospital Outpatient Quality Reporting) and private programs (URAC Health Plan with Health Insurance Exchange).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. The Musculoskeletal Standing Committee noted validity concerns regarding the exclusions in the measure. Specifically, patients with a history of prior back surgery and previous trauma were not among the exclusions. While there is an exclusion in the measure for patients with lumbar spine surgery in the 90 days prior to MRI, the Standing Committee noted that history of surgery should be an absolute exclusion, rather than a 90- day exclusion, as post-operative back surgery patients cannot be categorized as uncomplicated back pain patients.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Currently endorsed, however, the Standing Committee did not recommend the measure continued endorsement noting validity concerns with the measure exclusions and the use of multiple data sources to identify evaluation and management (E/M) claims.
Rationale for measure provided by HHS: Addresses imaging
efficiency/utilization gap and supports program alignment.
| National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome for program(s): HACRP (MUC ID: S0138) |
NQF Number (if applicable):
Programs under consideration: Hospital-Acquired Condition (HAC) Reduction Program
Preliminary analysis decision: Support
Preliminary analysis summary: UPDATE TO FINALIZED MEASURE) MAP is being asked to consider the implementation of an updated version of a measure currently in the HAC Reduction Program. This update was recently reviewed and recommended by the NQF Safety Standing Committee. Implementing this updated measure would extend the measure to hospital settings outside the ICU and add another risk adjustment methodology.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce riskFocus on reducing the major drivers of patient harmYes: The CDC estimates 54,500 catheter-associated urinary tract infections (CAUTI) occur annually in hospitals.[i] Rates of CAUTIs increased 3% between 2011 and 2012.[ii] CAUTIs are associated with longer hospital stays and are estimated to cost $340-$350 million annually.[iii]Overlap in measures between the HAC Reduction Program the Hospital Value-Based Purchasing Program can help to focus attention on critical safety issues. Yes: This measure is currently in the Hospital Value-Based Purchasing Program and the HAC Reduction Program. MAP is being asked to consider the implementation of an updated version of the measure. In its 2013-14 round of pre-rulemaking, MAP noted a number of gaps for this program: PSI-5 to address foreign bodies retained after surgery, and development of measures to address wrong site/wrong side surgery and sepsis beyond post-operative infections.N/A-this measure is already included in the HAC Reduction Program. MAP is being asked to consider the implementation of a revised version of the measure. [i] 2012 CDC National and State HAI Progress Report. [ii] http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is in use in the Hospital Inpatient Quality Reporting Program, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. This measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways:It has been extended to hospital settings outside the ICUAnother risk adjustment methodology was added to the measure. The two risk adjustment methodologies are:Standardized Infection Ratio (SIR) uses a stratification approach to compare CAUTIs incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CAUTIs in a medical ICU may be different then a general medical/surgical unit.Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Measure has been revised and
now in NQF re-endorsement process. CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters at the earliest possible time,
securing catheters to the patient´s leg to avoid bladder and urethral trauma,
keeping the urine collection bag below the level of the bladder, and utilizing
aseptic technique for urinary catheter insertion. These efforts will result in
decreased morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI monitoring,
leads to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another risk
adjustment methodology besides the Standardized Infection Ratio. The two risk
adjustment methodologies are: 1. Standardized Infection Ratio (annual and
quarter aggregation) The SIR is constructed by using an indirect
standardization method for summarizing HAI experience across any number of
stratified groups of data. CAUTI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CAUTI (and CAUTI rates) in a medical ICU are not
the same as in an SICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome for program(s): IQR (MUC ID: S0138) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: (UPDATE TO FINALIZED MEASURE)This high-impact fully specified, tested and endorsed outcome measure, which is part of the MAP Safety Family of Measures, is already in use in several public and private programs including IQR. MAP is being asked to consider the implementation of an updated version of the measure.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce riskIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events.N/A. This measure is currently in the IQR program measure set. MAP is being asked to consider an updated version of the measure. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps.N/AChoose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Yes: The CDC estimates 54,500 catheter-associated urinary tract infections (CAUTI) occur annually in hospitals.[i] Rates of CAUTIs increased 3% between 2011 and 2012.[ii] CAUTIs are associated with longer hospital stays and are estimated to cost $340-$350 million annually.[iii]Move towards more outcome measures rather than structure or process measures. Yes, this is an outcome measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. Yes: This measure is currently in the IQR program, the Hospital Value-Based Purchasing Program and the HAC Reduction Program. MAP is being asked to consider the implementation of an updated version of the measure. [i] 2012 CDC National and State HAI Progress Report. [ii] http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii]http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. Yes, this measure is in use in the Hospital Inpatient Quality Reporting Program, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways:It has been extended to hospital settings outside the ICUAnother risk adjustment methodology was added to the measure. The two risk adjustment methodologies are: Standardized Infection Ratio (SIR) uses a stratification approach to compare CLABSI incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CLABSI in a medical ICU may be different then a NICU. Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Measure has been revised and
now in NQF re-endorsement process. CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters at the earliest possible time,
securing catheters to the patient´s leg to avoid bladder and urethral trauma,
keeping the urine collection bag below the level of the bladder, and utilizing
aseptic technique for urinary catheter insertion. These efforts will result in
decreased morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI monitoring,
leads to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another risk
adjustment methodology besides the Standardized Infection Ratio. The two risk
adjustment methodologies are: 1. Standardized Infection Ratio (annual and
quarter aggregation) The SIR is constructed by using an indirect
standardization method for summarizing HAI experience across any number of
stratified groups of data. CAUTI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CAUTI (and CAUTI rates) in a medical ICU are not
the same as in an SICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome for program(s): MSSP (MUC ID: S0138) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending resolution of data concerns. MSSP might have difficulty accessing NHSN data and would need to coordinate with the CDC to obtain the information.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce risk· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Yes: this measure addresses an important patient safety concern for Medicare beneficiaries. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;o Response: Yes: The CDC estimates 54,500 catheter-associated urinary tract infections (CAUTI) occur annually in hospitals.[i] Rates of CAUTIs increased 3% between 2011 and 2012.[ii] CAUTIs are associated with longer hospital stays and are estimated to cost $340-$350 million annually.[iii]· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: N/A· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: Yes, this measure is in use in the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Inpatient Quality Reporting Program, the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, the Hospital Value-Based Purchasing Program (VBP), the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program, and the Long Term Care Hospital (LTCH) Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: N/A[i] 2012 CDC National and State HAI Progress Report. [ii] http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is in use in a number of federal, state, and private initiatives.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this measure has been NQF-endorsed since 2009. This measure is endorsed for the population level of analysis. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways:· It has been extended to hospital settings outside the ICU· Another risk adjustment methodology was added to the measure. The two risk adjustment methodologies are: o Standardized Infection Ratio (SIR) uses a stratification approach to compare CAUTIs incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CAUTIs in a medical ICU may be different then a general medical/surgical unit. o Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Is the measure NQF endorsed for the program's setting and level of analysis? .
Rationale for measure provided by HHS: Measure has been revised and
now in NQF re-endorsement process. CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters at the earliest possible time,
securing catheters to the patient´s leg to avoid bladder and urethral trauma,
keeping the urine collection bag below the level of the bladder, and utilizing
aseptic technique for urinary catheter insertion. These efforts will result in
decreased morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI monitoring,
leads to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another risk
adjustment methodology besides the Standardized Infection Ratio. The two risk
adjustment methodologies are: 1. Standardized Infection Ratio (annual and
quarter aggregation) The SIR is constructed by using an indirect
standardization method for summarizing HAI experience across any number of
stratified groups of data. CAUTI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CAUTI (and CAUTI rates) in a medical ICU are not
the same as in an SICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome for program(s): HVBP (MUC ID: S0138) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure supports the critical program objectives for the HVBP, is NQF-endorsed, has been tested for the appropriate level of analysis and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce risk Critical Program Objectives Include measures where there is a need and opportunity for improvement. The CDC estimates 54,500 catheter-associated urinary tract infections (CAUTI) occur annually in hospitals.[i] Rates of CAUTIs increased 3% between 2011 and 2012.[ii]Emphasize areas of critical importance for high performance and quality improvement, and ideally, link clinical quality and cost measures to capture value. CAUTIs are associated with longer hospital stays and are estimated to cost $340-$350 million annually.[iii]NQF-endorsed measures are strongly preferred.Yes: This measure is NQF-endorsed Keep the program measure set parsimonious to avoid diluting the payment incentives. N/A: This measure is currently in the program measure set. MAP is being asked to considerthe implementation of a revised version of the measure.MAP identified a number of gap areas that should be addressed within the VBP program measure set, including medication errors, mental and behavioral health, emergency department throughput, a hospital’s culture of safety, and patient and family engagement. N/A-this measure is already included in the Hospital Value-Based Purchasing Program. MAP is being asked to consider the implementation of a revised version of the measure.[i] 2012 CDC National and State HAI Progress Report. [ii] http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, the measure is appropriate for the facility level.
Is the measure currently in use? Yes. Yes, this measure is in use in the HAC Reduction Program, the Hospital Inpatient Quality Reporting Program, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives. The revised version of the measure is under consideration for VBP, IQR, and the HAC Reduction Program.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? . Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways: It has been extended to hospital settings outside the ICUAnother risk adjustment methodology was added to the measure. The two risk adjustment methodologies are: Standardized Infection Ratio (SIR) uses a stratification approach to compare CAUTIs incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CAUTIs in a medical ICU may be different then a general medical/surgical unit.Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Measure has been revised and
now in NQF re-endorsement process. CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary indwelling
catheters inserted, removing indwelling catheters at the earliest possible time,
securing catheters to the patient´s leg to avoid bladder and urethral trauma,
keeping the urine collection bag below the level of the bladder, and utilizing
aseptic technique for urinary catheter insertion. These efforts will result in
decreased morbidity and mortality and reduce healthcare costs. Use of this
measure to track CAUTIs through a nationalized standard for HAI monitoring,
leads to improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts. Additionally, CDC has added another risk
adjustment methodology besides the Standardized Infection Ratio. The two risk
adjustment methodologies are: 1. Standardized Infection Ratio (annual and
quarter aggregation) The SIR is constructed by using an indirect
standardization method for summarizing HAI experience across any number of
stratified groups of data. CAUTI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CAUTI (and CAUTI rates) in a medical ICU are not
the same as in an SICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome for program(s): HACRP (MUC ID: S0139) |
NQF Number (if applicable):
Programs under consideration: Hospital-Acquired Condition (HAC) Reduction Program
Preliminary analysis decision: Support
Preliminary analysis summary: (UPDATE TO FINALIZED MEASURE) MAP is being asked to consider the implementation of an updated version of a measure currently in the HAC Reduction Program. This update was recently reviewed and recommended by the NQF Safety Standing Committee. Implementing this updated measure would extend the measure to hospital settings outside the ICU and add another risk adjustment methodology.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce riskFocus on reducing the major drivers of patient harm.Yes: The CDC estimates that 41,000 central line-associated bloodstream infections (CLABSI) occur annually in acute care hospitals.[i] However, CLABSIs may be preventable with the use of proper central line insertion techniques and maintenance. Rates of CLABSIs decreased 44% between 2008 and 2012[ii]. CLABSI is associated with longer hospital stays, up to a 25% mortality rate[iii], and an annual total cost of $0.6 billion-2.7 billion.[iv]Overlap in measures between the HAC Reduction Program the Hospital Value-Based Purchasing Program can help to focus attention on critical safety issues.Yes: This measure is currently in the Hospital Value-Based Purchasing Program and the HAC Reduction Program. MAP is being asked to consider the implementation of an updated version of the measure. In its 2013-14 round of pre-rulemaking, MAP noted a number of gaps for this program: PSI-5 to address foreign bodies retained after surgery, and development of measures to address wrong site/wrong side surgery and sepsis beyond post-operative infections.N/A-this measure is already included in the HAC Reduction Program. MAP is being asked to consider the implementation of a revised version of the measure. [i] http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf[ii] CDC. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii]http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/CDC_VitalSignsReportMarch2011.pdf[iv] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. Yes, this measure is in use in the Hospital Inpatient Quality Reporting Program, The Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways: It has been extended to hospital settings outside the ICU Another risk adjustment methodology was added to the measure. The two risk adjustment methodologies are:Standardized Infection Ratio (SIR) uses a stratification approach to compare CLABSI incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CLABSI in a medical ICU may be different then a NICU.Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Updated version of a current
measure in IQR, HVBP, and HACRP CLABSI can be minimized through proper
management of the central line. Efforts to improve central line insertion and
maintenance practices, with early discontinuance of lines are recommended. These
efforts result in decreased morbidity and mortality and reduced healthcare
costs. Use of this measure to track CLABSIs through a nationalized standard for
HAI monitoring, leads to improved patient outcomes and provides a mechanism for
identifying improvements and evaluating prevention efforts. Additionally, CDC
has added another risk adjustment methodology besides the Standardized Infection
Ratio. The two risk adjustment methodologies are: 1. Standardized Infection
Ratio (annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any number
of stratified groups of data. CLABSI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome for program(s): IQR (MUC ID: S0139) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: (UPDATE TO FINALIZED MEASURE)This high-impact fully specified, tested and endorsed outcome measure, which is part of the MAP Safety Family of Measures, is already in use in several public and private programs including IQR. MAP is being asked to consider the implementation of an updated version of the measure.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce risk In the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events.N/A. This measure is currently in the IQR program measure set. MAP is being asked to consider an updated version of the measure. Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Yes: The CDC estimates that 41,000 central line-associated bloodstream infections (CLABSI) occur annually in acute care hospitals.[i] However, CLABSIs may be preventable with the use of proper central line insertion techniques and maintenance. Rates of CLABSIs decreased 44% between 2008 and 2012[ii]. CLABSI is associated with longer hospital stays, up to a 25% mortality rate[iii], and an annual total cost of $0.6 billion-2.7 billion.[iv]Move towards more outcome measures rather than structure or process measures. Yes, this is an outcome measure. Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes: This measure is currently in the IQR program, the Hospital Value-Based Purchasing Program and the HAC Reduction Program. MAP is being asked to consider the implementation of an updated version of the measure. [i] http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf[ii] CDC. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii]http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/CDC_VitalSignsReportMarch2011.pdf[iv] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. Yes, this measure is in use in the Hospital Inpatient Quality Reporting Program, The Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project.This measure has been updated in two ways:It has been extended to hospital settings outside the ICUAnother risk adjustment methodology was added to the measure. The two risk adjustment methodologies are: Standardized Infection Ratio (SIR) uses a stratification approach to compare CLABSI incidence rates.For example, the stratification can be by the hospital’s patient care location as the predicted number of CLABSI in a medical ICU may be different then a NICU. Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Updated version of a current
measure in IQR, HVBP, and HACRP CLABSI can be minimized through proper
management of the central line. Efforts to improve central line insertion and
maintenance practices, with early discontinuance of lines are recommended. These
efforts result in decreased morbidity and mortality and reduced healthcare
costs. Use of this measure to track CLABSIs through a nationalized standard for
HAI monitoring, leads to improved patient outcomes and provides a mechanism for
identifying improvements and evaluating prevention efforts. Additionally, CDC
has added another risk adjustment methodology besides the Standardized Infection
Ratio. The two risk adjustment methodologies are: 1. Standardized Infection
Ratio (annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any number
of stratified groups of data. CLABSI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome for program(s): MSSP (MUC ID: S0139) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending resolution of data concerns. MSSP might have difficulty accessing NHSN data and would need to coordinate with the CDC to obtain the information.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce risk§ This measures focuses on a high risk safety area with known evidence based interventions to reduce risk· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Yes: this measure addresses an important patient safety concern for Medicare beneficiaries. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: The CDC estimates that 41,000 central line-associated bloodstream infections (CLABSI) occur annually in acute care hospitals.[i] However, CLABSIs may be preventable with the use of proper central line insertion techniques and maintenance. Rates of CLABSIs decreased 44% between 2008 and 2012[ii]. CLABSI is associated with longer hospital stays, up to a 25% mortality rate[iii], and an annual total cost of $0.6 billion-2.7 billion.[iv]· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: N/A· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: Yes, this measure is in use in the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Inpatient Quality Reporting Program, the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, the Hospital Value-Based Purchasing Program (VBP), the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program, and the Long Term Care Hospital (LTCH) Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: N/A[i] http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf[ii] CDC. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii]http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/CDC_VitalSignsReportMarch2011.pdf[iv] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. Yes, this measure is in use in the HAC Reduction Program, the Hospital Inpatient Quality Reporting Program, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. Yes, this is an outcome measure addressing a common and costly patient safety concern that is widely used. However, there may be concerns about data source compatibility that should be addressed before adding this measure to the MSSP program.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure is endorsed for the population level of analysis. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways:· It has been extended to hospital settings outside the ICU· Another risk adjustment methodology was added to the measure. The two risk adjustment methodologies are: o Standardized Infection Ratio (SIR) uses a stratification approach to compare CLABSI incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CLABSI in a medical ICU may be different then a NICU. o Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Updated version of a current
measure in IQR, HVBP, and HACRP CLABSI can be minimized through proper
management of the central line. Efforts to improve central line insertion and
maintenance practices, with early discontinuance of lines are recommended. These
efforts result in decreased morbidity and mortality and reduced healthcare
costs. Use of this measure to track CLABSIs through a nationalized standard for
HAI monitoring, leads to improved patient outcomes and provides a mechanism for
identifying improvements and evaluating prevention efforts. Additionally, CDC
has added another risk adjustment methodology besides the Standardized Infection
Ratio. The two risk adjustment methodologies are: 1. Standardized Infection
Ratio (annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any number
of stratified groups of data. CLABSI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome for program(s): HVBP (MUC ID: S0139) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives for HVBP, has been tested at the appropriate facility level, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. This measures focuses on a high risk safety area with known evidence based interventions to reduce risk ?Critical Program Objectives: Include measures where there is a need and opportunity for improvement. Yes: The CDC estimates that 41,000 central line-associated bloodstream infections (CLABSI) occur annually in acute care hospitals.[i] However, CLABSIs may be preventable with the use of proper central line insertion techniques and maintenance. Rates of CLABSIs decreased 44% between 2008 and 2012[ii]. Emphasize areas of critical importance for high performance and quality improvement, and ideally, link clinical quality and cost measures to capture value.Yes: CLABSI is associated with longer hospital stays, up to a 25% mortality rate[iii], and an annual total cost of $0.6 billion-2.7 billion.[iv]NQF-endorsed measures are strongly preferred.Yes: This measure is NQF-endorsedKeep the program measure set parsimonious to avoid diluting the payment incentives.N/A: This measure is currently in the program measure set. MAP is being asked to considerthe implementation of a revised version of the measure.MAP identified a number of gap areas that should be addressed within the VBP program measure set, including medication errors, mental and behavioral health, emergency department throughput, a hospital’s culture of safety, and patient and family engagement.N/A-this measure is already included in the Hospital Value-Based Purchasing Program. MAP is being asked to consider the implementation of a revised version of the measure. [i] http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf[ii] CDC. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf[iii]http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/CDC_VitalSignsReportMarch2011.pdf[iv] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, the measure is appropriate for the facility level.
Is the measure currently in use? Yes. Yes, this measure is in use in the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Inpatient Quality Reporting Program, The Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, IRF Quality Reporting Program, and LTCH Quality Reporting Program. Additionally this measure is in use in the National Healthcare Safety Network and a number of state and private initiatives. The revised version of the measure is under consideration for VBP, IQR, and the HAC Reduction Program.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure is used in a number of other hospital programs, supporting alignment and parsimony. Additionally, this measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? . Yes, this measure has been NQF-endorsed since 2009. This measure was recommended for continuing endorsement in the Endorsement Maintenance: Patient Safety Measures project. This measure has been updated in two ways: It has been extended to hospital settings outside the ICUAnother risk adjustment methodology was added to the measure. The two risk adjustment methodologies are:Standardized Infection Ratio (SIR) uses a stratification approach to compare CLABSI incidence rates. For example, the stratification can be by the hospital’s patient care location as the predicted number of CLABSI in a medical ICU may be different then a NICU. Adjusted Ranking Metric (ARM) uses a more complex Bayesian estimation technique to account for the small sample sizes that may be present in the strata described in the SIR above. To adjust for this potentially low precision and/or reliability due to sample size, a statistical adjustment is made to the numerator.
Rationale for measure provided by HHS: Updated version of a current
measure in IQR, HVBP, and HACRP CLABSI can be minimized through proper
management of the central line. Efforts to improve central line insertion and
maintenance practices, with early discontinuance of lines are recommended. These
efforts result in decreased morbidity and mortality and reduced healthcare
costs. Use of this measure to track CLABSIs through a nationalized standard for
HAI monitoring, leads to improved patient outcomes and provides a mechanism for
identifying improvements and evaluating prevention efforts. Additionally, CDC
has added another risk adjustment methodology besides the Standardized Infection
Ratio. The two risk adjustment methodologies are: 1. Standardized Infection
Ratio (annual and quarter aggregation) The SIR is constructed by using an
indirect standardization method for summarizing HAI experience across any number
of stratified groups of data. CLABSI incidence rates stratified by patient care
location type and in some instances, location bed size and type of medical
school affiliation which form the basis of the population standardization.
Example: predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not
the same as in an NICU. See also Scientific Validity section for further
information on risk adjustment and variables. 2. Adjusted Ranking Metric
(annual aggregation) The adjusted ranking metric (ARM) combines the method of
indirect standardization with a Bayesian random effects hierarchical model to
account for the potentially low precision and/or reliability inherent in the
unadjusted SIR mentioned above. A Bayesian posterior distribution constructed
through Monte Carlo Markov Chain sampling is used to produce the adjusted
numerator.
| National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure for program(s): PCHQR (MUC ID: E1717) |
NQF Number (if applicable): 1717
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals.Yes. In its Performance Measurement Coordination Strategy for PPS-Exempt Cancer Hospitals, MAP identified safety as a priority area. Clostridium difficile infection is a significant cause of morbidity and mortality among hospital patients and is associated with increased healthcare costs[i]. CDI has been found to cause 12% of healthcare associated infections[ii], have a mortality rate of 16.7% after one year[iii], and have a total cost per year of $1 billion to 1.6 billion[iv]. Incidence and severity of C. difficile infections appears to be rising[v] with the CDC estimating that 107, 700 infections occurred in United States acute care hospitals in 2011[vi]. Adherence to clinical guidelines has been down to result decreased rates of infection[vii]. Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant. Yes. This measure is currently in the Inpatient Quality Reporting Program measure set. The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this program. While this measure does not address a gap specifically identified for this program, MAP stressed the importance of safety measures in its Coordination Strategy for PPS-Exempt Cancer Hospitals. [i] http://www.uptodate.com/contents/clostridium-difficile-infection-prevention-and-control?source=search_result&search=Clostridium+difficile+Infection&selectedTitle=4~150[ii] Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. N Engl J Med 2014;370:1198-208.[iii] Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals • Erik R. Dubberke, MD; Dale N. Gerding, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Victoria Fraser, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPHInfection Control and Hospital Epidemiology, Vol. 29, No. S1, A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals (October 2008), pp. S81-S92[iv] http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf[v] Lessa, Fernanda et al. Current Status of Clostridium difficile Infection Epidemiology. Clinical Infect. Dis. (2012). [vi] 2012 CDC National and State HAI Progress Report. [vii] Cohen SH, Gerding DN, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol, 2010. 31(5):431-455.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, it is tested for the hospital setting.
Is the measure currently in use? Yes. Yes, it is being used in the Inpatient Quality Reporting Program, the Hospital Value-Based Purchasing Program, and the Long-Term Care Hospital Quality Reporting Program. It is also used in programs by the AmeriHealth Mercy Family of Companies and Wellpoint.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? . This measure is not duplicative of an existing measure in the PCHQR program. This measure would promote alignment between programs assessing general acute care and cancer hospitals (IQR and PCHQR). This measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #1717.
Rationale for measure provided by HHS: Addresses a gap in the program
Clinical guidelines for the management of C. difficile have been published.
Adherence to the recommendations in the guidelines can result in decreased rates
of C. difficile transmission and infection. Decreasing rates of infection will
result in a lower SIR, which indicates improving performance. Cohen SH, Gerding
DN, et al. Clinical Practice Guidelines for Clostridium difficile Infection in
Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA)
and the Infectious Diseases Society of America (IDSA). Infect Control Hosp
Epidemiol, 2010. 31(5):431-455. Rutala WA, Weber DJ, and the Healthcare
Infection Control Practices Advisory Committee. Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008. Available at
http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf. Siegel JD,
Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control
Practices Advisory Committee. 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings. Available
at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Boyce JM, Pittet
D, et al. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of
the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 2002. 51(RR-16).
| National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure for program(s): PCHQR (MUC ID: E1716) |
NQF Number (if applicable): 1716
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Yes. In its Performance Measurement Coordination Strategy for PPS-Exempt Cancer Hospitals MAP identified safety as a priority area. The CDC estimates that 48,000 invasive MRSA infections occurred in hospitals in 2011.[i] Although MRSA rates are declining, MRSA may account for up to 8.5% of all healthcare-associated infections.[ii] Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant. Yes. This measure is currently in the Inpatient Quality Reporting Program measure set. The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this program [i] Dantes R, Mu Y, Belflower R, et al. National Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections, United States, 2011. JAMA Intern Med. 2013;173(21):1970-1978. doi:10.1001/jamainternmed.2013.10423[ii] Antimicrobial-Resistant Pathogens Associated with Healthcare-Associated Infections: Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010Dawn M. Sievert, PhD; Philip Ricks, PhD; Jonathan R. Edwards, MS; Amy Schneider, MPH; Jean Patel, PhD; Arjun Srinivasan, MD; Alex Kallen, MD; Brandi Limbago, PhD; Scott Fridkin, MD; for the National Healthcare Safety Network (NHSN) Team and Participating NHSN FacilitiesInfection Control and Hospital Epidemiology, Vol. 34, No. 1 (January 2013), pp. 1-14
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes, it has been tested and is being used in the hospital setting.
Is the measure currently in use? Yes. Yes, it is being used in the Inpatient Quality Reporting Program, the Hospital Value-Based Purchasing Program, and the Long-Term Care Hospital Quality Reporting Program. It is also used in programs by the AmeriHealth Mercy Family of Companies and Wellpoint.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? . This measure is not duplicative of an existing measure in the PCHQR program. This measure would promote alignment between programs assessing general acute care and cancer hospitals (IQR and PCHQR). This measure is included in the MAP Safety Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #1716.
Rationale for measure provided by HHS: Cover gap in program and for
measure alignment The SIR compares a healthcare facility´s performance compared
to a national baseline. Facilities are able to see whether the number of LabID
events that they have reported compares to the number that would be expected,
given national data. The measure can then be used to drive prevention practices
that will lead to improved outcomes, including the reduction of patient
morbidity and mortality. Siegel, JD, et al., Guideline for Management of
Multidrug-Resistant Organisms In Healthcare Settings, 2006. Available at
http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf.
| Needle biopsy to establish diagnosis of cancer precedes surgical excision/resection for program(s): PCHQR (MUC ID: E0221) |
NQF Number (if applicable): 0221
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQPR, has been tested for the appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Breast cancer is the second most common type of cancer and is the second most common cause of cancer death for women in the United States.[i] For patients with suspected breast cancer, a needle biopsy should be performed to confirm the diagnosis prior to surgery.[ii] Needle biopsy has been found to be as accurate as surgical biopsy but is associated with lower complications, decreased morbidity, lower cost, and increased patient satisfaction.[iii],[iv],[v]Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant.The measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this program[i] 2014 UptoDate. Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer. [ii] 2014 UptoDate. Breast Biopsy. [iii] Bruening W, Fontanarosa J, Tipton K et al. Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med 2010;152(4):238-46.[iv] Golub RM, Bennett CL, Stinson T et al. Cost minimation study of image-guided core biopsy versus surgical excisional biopsy for women with abnormal mammograms. J Clin Oncol 2004;22(12):2430-7.[v] Silverstein MJ, Recht A, Lagois MD et al. Image detected breast cancer: State-of-the-art diagnosis and treatment. J Am Coll Surg 2009;209:504-19.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes, it is tested for the hospital setting/acute care facility level.
Is the measure currently in use? Yes. Yes, this measure is used by the American College of Surgeons’ Commission on Cancer. The measure has been in use by the Commission on Cancer since 2007.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, the measure is not duplicative of another measure in the PCHQR program. While this measure is not used in another federal program, it is part of the MAP Cancer Family of Measures. This measure would fill a gap in breast cancer care previously identified by the Hospital workgroup.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, the measure is endorsed - #0221.
Rationale for measure provided by HHS: Improve the utilization of
needle biopsy prior to surgery for breast cancer with resultant decreased
morbidity and increased cost effectiveness, and patient satisfaction Williams
RT, Yao KT, Stewart AK et al. Needle versus excisional biopsy for noninvasive
and invasive breast cancer, report from the National Cancer Data Base 2003-2008.
Ann Surg Oncol 2011;18(13):3802-10. 2. Friese CR, Neville BA, Edge SB et al.
Breast biopsy patterns and outcomes in Surveillance, Epidemiology, and End
Results-Medicare data. Cancer 2009;115(4):716-24. 3. Holloway CM, Saskin R,
Paszat L. Geographic variation and physician specialization in the use of
percutaneous biopsy for breast cancer diagnosis. Can J Surg 2008;51(6):453-63.
4. Clarke-Pearson EM, Jacobson AF, Boolbol SK et al. Quality assurance
initiative at one institution for minimally invasive breast biopsy as the
initial diagnostic technique. J Am Coll Surg 2009;208(1):75-8.
| Normothermia Outcome for program(s): ASCQRP (MUC ID: X3719) |
NQF Number (if applicable): N/A
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the completion of reliability testing and NQF endorsement. This high impact measure fulfills the MAP identified gap of anesthesia related complications but reliability testing is not completed and the measure is not NQF endorsed.
Does the measure address a critical program objective as defined by MAP? Yes. The measure is a high impact measure. Anesthetic-induced thermoregulatory impairment may cause perioperative hypothermia, which is associated with adverse outcomes including significant morbidity (decrease in tissue metabolic rate, myocardial ischemia, surgical site infections, bleeding diatheses, prolongation of drug effects) and mortality[1]. The World Health Organization has issued an Anesthesia Safety Checklist including preoperative and postoperative care guidelines[2]. As an intermediate outcome measure, this measure moves towards an outcome measure that fills the workgroup identified gap of anesthesia related complications.Critical Objectives: Include measures that have high impact and are meaningful to patients.Anesthetic-induced thermoregulatory impairment may cause perioperative hypothermia, which is associated with adverse outcomes including significant morbidity (decrease in tissue metabolic rate, myocardial ischemia, surgical site infections, bleeding diatheses, prolongation of drug effects) and mortality[3]. The World Health Organization has issued an Anesthesia Safety Checklist including preoperative and postoperative care guidelines.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not in or under review for any programs.Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure is related to complications including anesthesia related complications. [1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179201/pdf/i1524-5012-11-3-259.pdf [2] http://www.who.int/surgery/publications/s15980e.pdf[3] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179201/pdf/i1524-5012-11-3-259.pdf
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested in the ambulatory setting. All testing except reliability testing has been completed. Reliability testing started July2014.
Is the measure currently in use? No. This measure is not currently in use in any public or private programs
Does the measure promote alignment and parsimony? Yes. This measure supports alignment by filling the gap of anesthesia related complications
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has never been submitted or modified for NQF-endorsement for the program’s setting and level of analysis.
Rationale for measure provided by HHS: Anesthetic-induced
thermoregulatory impairment may cause perioperative hypothermia, which is
associated with adverse outcomes.
| Nursing Hours per Patient Day for program(s): IQR (MUC ID: E0205) |
NQF Number (if applicable): 0205
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Do not support
Preliminary analysis summary: The IQR program currently includes measures that assess the outcomes addressed by nurse staffing levels. MAP has previously noted its desire for the most parsimonious measure sets possible and for outcome measures to be used in place of structural measures when possible.
Does the measure address a critical program objective as defined by MAP? Yes. This measure focuses on higher levels of nurse staffing which has been found to be associated with better patient outcomes, including shorter length of stay, lower rates of mortality, failure to rescue, hospital acquired infections, medication errors and pressure ulcers, is high impact and is in use in a number of payroll, accounting, and HR systems as well as a number of quality programsCritical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, higher levels of nurses staffing have been found to be associated with better patient outcomes, including shorter length of stay, lower rates of mortality, failure to rescue, hospital acquired infections, medication errors and pressure ulcers. Move towards more outcome measures rather than structure or process measures.No, this is a structural measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is in use in a number of payroll, accounting, and HR systems as well as a number of quality programs.Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. No, nurse staff was not named as a gap for the IQR program.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the facility level.
Is the measure currently in use? Yes. Yes, this measure is currently in use in a number of programs including the Department of Banking, Insurance, Securities and Health Care Administration, the Vermont Hospital Report Card, the Colorado Hospital Report Card Norton Healthcare, Kentucky, and the Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? No. No, while there is evidence that nurse staffing levels can influence outcomes this is a structural measure and MAP has previously indicated its desire to use outcome measures when possible. The outcomes influenced by nurse staffing are largely addressed by outcome measures currently in the program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is NQF #0205.
Rationale for measure provided by HHS: With the increasing concerns
about cost and quality of patient care over the past 2 decades, hospital nurse
staffing has become a major focus in examining health care workforce
relationships with patient outcomes. Nurses are the largest group of clinical
providers of care in healthcare systems. The Institute of Medicine recently
concluded, in its report, The Future of Nursing: Leading Changing, Advancing
Health (2010), that nurses are vital in providing quality care to patients. A
large body of research has demonstrated that higher nurse staffing levels are
significantly associated with better patient outcomes, including shorter length
of stay and lower rates of mortality, failure to rescue, hospital acquired
infections, falls, medication errors, and pressure ulcers (Blegen, Goode,Spetz,
Vaughn, & Park, 2011; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007;
Lake & Cheung, 2006; Lang, Hodge, Olson, Romano, & Kravitz, 2004;
Lankshear, Sheldon, & Maynard, 2005; Needleman et al., 2011; Stone et al.,
2007; Unruh, 2008). The Agency for Healthcare Research and Quality (AHRQ)
conducted a comprehensive and systematic review of the 97 observational studies
on the relationship between nurse staffing and patient outcomes published
between 1990 and 2006. This AHRQ’s meta-analysis found a strong and consistent
relationship between nurse staffing and specific patient outcomes (mortality and
length of stay), particularly for patients in intensive care units and surgical
units (Kane et al., 2007). For example, length of stay was shorter by 24% in
intensive care units and by 31% in surgical units as 1 RN per patient day was
increased. In addition, nurse staffing affects care costs. There was evidence
that an additional RN hour per patient day or a 10% increase in the proportion
of RNs decreased the odds of patients’ pneumonia by 8.9% or 9.5%, respectively
(Cho, 2003). American Nurses Association (ANA). (2012). ANA’s Principles for
Nurse Staffing, 2nd Edition, Nursebooks.org, Silver Spring, MD. Blegen, M. A.,
Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing
effects on patient outcomes: safety-net and non-safety-net hospitals. Medical
Care, 49(4), 406-414. Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith,
D. G. (2003). The effects of nurse staffing on adverse events, morbidity,
mortality, and medical costs. Nursing Research, 52(2), 71-79. Elliott, M.N.,
Kanouse, D.E., Edwards, C.A., & Hilborne, L.H. (2009). Components of care
vary in importance for overall patient-reported experience by type of
hospitalization. Medicare Care, (47), 842–849. Institute of Medicine. (2011).
The future of nursing: Leading change, advancing health. Wahington, D.C.:
National Academies Press. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval,
S., & Wilt, T. J. (2007). The association of registered nurse staffing
levels and patient outcomes: systematic review and meta-analysis. Medical Care,
45(12), 1195-1204. Kutney-Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P.,
Flynn, L., Neff, D.F., Aiken, L.H. (2009). Nursing: a key to patient
satisfaction. Health Affairs, 28(4). Epub 2009 Jun 12. Lake, E. T., &
Cheung, R. B. (2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse
Staffing? Western Journal of Nursing Research, 28(6), 654-677. Lang, T. A.,
Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L. (2004). Nurse-patient
ratios: a systematic review on the effects of nurse staffing on patient, nurse
employee, and hospital outcomes. Journal of Nursing Administration, 34(7-8),
326-337. Lankshear, A. J., Sheldon, T. A., & Maynard, A. (2005). Nurse
staffing and healthcare outcomes: a systematic review of the international
research evidence. Advances in Nursing Science, 28(2), 163-174. Needleman, J.,
Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M.
(2011). Nurse staffing and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037-1045. Nursing Alliance for Quality Care (NAQC). (
| Nursing Information for program(s): OQR (MUC ID: E0296) |
NQF Number (if applicable): 0296
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set, which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the nursing information, which includes any assessments, interventions, impairments, catheters, immobilizations, respiratory support, oral limitations that were performed or occurred during the patients time in the departing facility, was communicated to the receiving facility within 60 minutes of departure.Critical Objectives: Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: No Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patients who are transferred
from an Emergency Department to another acute facility are excluded from the
calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD 2006,
Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).
Communication problems are a major contributing factor to adverse events in
hospitals, accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care physicians in
the community (Kripalani S 2007), and between hospitals and long term facilities
(Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal
#2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement
2E for this goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician hand-offs
from the emergency department to inpatient units, other hospitals, and other
types of health care facilities. The process must include a method of
communicating up-to-date information regarding the patient’s care, treatment and
services, condition and any recent or anticipated changes (JCAHO-2 2007). 1.
Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in
Hospitalized Patients. Results of the Harvard Medical Practice Study II. New
England Journal of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D.,
Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in
Utah and Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments. Academic
Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C.
and Reese, C. Emergency Department Performance Measures and Benchmarking Summit.
Academic Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell
KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care
hospital emergency departments. . Academic Emergency Medicine 13:746-754, 2006.
6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
hospitals in Kansas. Journal of Rural Health. 20:363-367, 2004.
| O/ASPECS About Facility and Staff for program(s): ASCQRP (MUC ID: X3698) |
NQF Number (if applicable):
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure would fill a gap previously identified by MAP around patient and family engagement and provide consumers with meaningful information.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey asks six specific questions about the patient’s experience with the facility including facility cleanliness and staff interaction. This is a high impact measure that will improve both quality and efficiency of care and will be meaningful to consumers. This measure is also under consideration for the Hospital Outpatient Quality Reporting program.Critical Objectives:Include measures that have high impact and are meaningful to patients. This measure is highly impactful and meaningful because patient experience of care measures are a MAP priority.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not currently in use but under consideration for Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority gap area and includes an ASC-specific CAHPS module and patient-reported outcome measures.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an ASC-specific CAHPS patient-reported outcome measure that captures a broad population, the MUC contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their treatment experience, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS About Facility and Staff for program(s): OQR (MUC ID: X3698) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey asks six specific questions about the patient’s experience with facility including cleanliness and staff interaction, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Ambulatory Surgical Center Quality Reporting program.Critical Objectives: Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. This measure is not currently in use but under consideration for Ambulatory Surgical Center Quality Reporting program. Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.This measure is an outpatient CAHPS module gap, thus address a gap in patient-reported outcome measures, and patient and family engagement.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an outpatient CAHPS patient-reported outcome measure that captures a broad population, this measure contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Communication for program(s): ASCQRP (MUC ID: X3699) |
NQF Number (if applicable):
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure would fill a gap previously identified by MAP around patient and family engagement and would provide meaningful information to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that asks five specific questions regarding the clarity of the information provided by staff about the patient’s condition, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Hospital Outpatient Quality Reporting program.Critical Objectives:Include measures that have high impact and are meaningful to patients.This measure is highly impactful and meaningful because patient experience of care measures are a MAP priority.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not currently in use but under consideration for Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority gap area and includes an ASC-specific CAHPS module and patient-reported outcome measures.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an ASC-specific CAHPS patient-reported outcome measure that captures a broad population, the MUC contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Communication for program(s): OQR (MUC ID: X3699) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that asks five specific questions regarding the clarity of the information provided by staff about the patient’s condition, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Ambulatory Surgical Center Quality Reporting program.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. This measure is not currently in use but under consideration for Ambulatory Surgical Center Quality Reporting program. Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.This measure is an outpatient CAHPS module gap, thus address a gap in patient-reported outcome measures, and patient and family engagement.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an outpatient CAHPS patient-reported outcome measure that captures a broad population, this measure contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Discharge and Recovery for program(s): ASCQRP (MUC ID: X3697) |
NQF Number (if applicable):
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure would fill a gap previously identified by MAP around patient and family engagement and would provide meaningful information to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that asks five specific questions regarding the communication of discharge instructions and follow-up after discharge, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Hospital Outpatient Quality Reporting program. Critical Objectives:Include measures that have high impact and are meaningful to patients. This measure is highly impactful and meaningful because patient experience of care measures are a MAP priority.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not currently in use but under consideration for Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority gap area and includes an ASC-specific CAHPS module and patient-reported outcome measures.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an ASC-specific CAHPS patient-reported outcome measure that captures a broad population, the MUC contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Discharge and Recovery for program(s): OQR (MUC ID: X3697) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey asks five specific questions regarding the communication of discharge instructions and follow-up after discharge, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Ambulatory Surgical Center Quality Reporting program.Critical Objectives: Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. This measure is not currently in use but under consideration for Ambulatory Surgical Center Quality Reporting program. Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.This measure is an outpatient CAHPS module gap, thus address a gap in patient-reported outcome measures, and patient and family engagement.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes. In beta testing
Is the measure currently in use? No. This measure is still under development.
Does the measure promote alignment and parsimony? . As an outpatient CAHPS patient-reported outcome measure that captures a broad population, this measure contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure under consideration is not NQF-endorsed or fully specified for the program’s setting and level of analysis.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Overall Facility Rating for program(s): ASCQRP (MUC ID: X3702) |
NQF Number (if applicable):
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure would help to fill a gap previously identified by MAP and would provide meaningful information to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that rates the patient’s experience with the overall facility, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Hospital Outpatient Quality Reporting program.Critical Objectives:Include measures that have high impact and are meaningful to patients.This measure is highly impactful and meaningful because patient experience of care measures are a MAP priority. Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not currently in use but under consideration for Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority gap area and includes an ASC-specific CAHPS module and patient-reported outcome measures.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an ASC-specific CAHPS patient-reported outcome measure that captures a broad population, the MUC contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their treatment experience, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Overall Facility Rating for program(s): OQR (MUC ID: X3702) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that rates the patient’s experience with the overall facility, this is a high impact measure that will improve both quality and efficiency of care and is meaningful to consumers. This measure is also under consideration for the Ambulatory Surgical Center Quality Reporting program.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. This measure is not currently in use but under consideration for Ambulatory Surgical Center Quality Reporting program. Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.This measure is an outpatient CAHPS module gap, thus address a gap for patient-reported outcome measure, and patient and family engagement.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an outpatient CAHPS patient-reported outcome measure that captures a broad population, this measure contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Recommend for program(s): ASCQRP (MUC ID: X3703) |
NQF Number (if applicable):
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure would help to fill a previously identified gap around patient and family engagement and would provide meaningful information to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that asks if the patient would recommend the facility to family and friends, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Hospital Outpatient Quality Reporting program.Critical Objectives:Include measures that have high impact and are meaningful to patients.This measure is highly impactful and meaningful because patient experience of care measures are a MAP priority.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programs.This measure is not currently in use but under consideration for Hospital Outpatient Quality Reporting program. Priority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures.This measure addresses the patient and family engagement priority gap area and includes an ASC-specific CAHPS module and patient-reported outcome measures.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. This ASC-specific CAHPS patient-reported outcome measure captures a broad population and this MUC contributes to an efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their treatment experience, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| O/ASPECS Recommend for program(s): OQR (MUC ID: X3703) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers.
Does the measure address a critical program objective as defined by MAP? Yes. As a patient-reported outcome outpatient/ambulatory surgery patient experience of care survey that asks if the patient would recommend the facility to family and friends, this is a high impact measure that will improve both quality and efficiency of care and be meaningful to consumers. This measure is also under consideration for the Ambulatory Surgical Center Quality Reporting programm. Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. This measure is not currently in use but under consideration for Ambulatory Surgical Center Quality Reporting program. Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.This measure is an outpatient CAHPS module gap, thus address a gap in patient-reported outcome measures, and patient and family engagement.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? In beta testing
Is the measure currently in use?
Does the measure promote alignment and parsimony? Yes. As an outpatient CAHPS patient-reported outcome measure that captures a broad population, this measure contributes to the efficient use of measurement resources and supports alignment across programs. This is a high value measure because the patient provides the data about their results of treatment, level of function and health status.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Patient experience of care
measures are a CMS priority
| Paired Measures 0702 and 0703; Intensive Care Unit (ICU) Length-of-Stay (LOS) and Intensive Care: In-hospital mortality rate for program(s): IQR (MUC ID: E2104) |
NQF Number (if applicable): 2104
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Angus DC, Linde-Zwirble WT,
Sirio CA, et al. The effect of managed care on ICU length of stay: implications
for Medicare. JAMA. Oct 2 1996;276(13):1075-1082. Wu AW, Pronovost P, Morlock
L. ICU incident reporting systems. J Crit Care. Jun 2002;17(2):86-94. Young MP,
Birkmeyer JD. Potential reduction in mortality rates using an intensivist model
to manage intensive care units. Eff Clin Pract. Nov-Dec 2000;3(6):284-289.
Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable
adverse drug events in hospitalized patients: a comparative study of intensive
care and general care units. Crit Care Med. Aug 1997;25(8):1289-1297. Andrews
LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse
events in medical care. Lancet. Feb 1 1997;349(9048):309-313. Giraud T,
Dhainaut JF, Vaxelaire JF, et al. Iatrogenic complications in adult intensive
care units: a prospective two-center study. Crit Care Med. Jan 1993;21(1):40-51.
Pronovost P, Wu AW, Dorman T, Morlock L. Building safety into ICU care. J Crit
Care. Jun 2002;17(2):78-85. Halpern NA, Pastores SM. Critical care medicine in
the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer
mix, and costs. Crit Care Med. Jan 2010;38(1):65-71. Rapoport J, Teres D,
Lemeshow S, Avrunin JS, Haber R. Explaining variability of cost using a
severity-of-illness measure for ICU patients. Med Care. Apr 1990;28(4):338-348.
Rapoport J, Teres D, Lemeshow S, Gehlbach S. A method for assessing the clinical
performance and cost-effectiveness of intensive care units: a multicenter
inception cohort study. Crit Care Med. Sep 1994;22(9):1385-1391. Gunning K,
Rowan K. ABC of intensive care: outcome data and scoring systems. BMJ. Jul 24
1999;319(7204):241-244. Shortell SM, Zimmerman JE, Gillies RR, et al.
Continuously improving patient care: practical lessons and an assessment tool
from the National ICU Study. QRB Qual Rev Bull. May 1992;18(5):150-155.
Kuzniewicz MW, Vasilevskis EE, Lane R, et al. Variation in ICU risk-adjusted
mortality: impact of methods of assessment and potential confounders. Chest. Jun
2008;133(6):1319-1327. Rothen HU, Stricker K, Einfalt J, et al. Variability in
outcome and resource use in intensive care units. Intensive Care Med. Aug
2007;33(8):1329-1336. Knaus WA, Wagner DP, Zimmerman JE, Draper EA. Variations
in mortality and length of stay in intensive care units. Ann Intern Med. May 15
1993;118(10):753-761. Render ML, Kim HM, Deddens J, et al. Variation in
outcomes in Veterans Affairs intensive care units with a computerized severity
measure. Crit Care Med. May 2005;33(5):930-939. Vasilevskis EE, Kuzniewicz MW,
Cason BA, et al. Mortality probability model III and simplified acute physiology
score II: assessing their value in predicting length of stay and comparison to
APACHE IV. Chest. Jul 2009;136(1):89-101. Rosenthal GE, Harper DL, Quinn LM,
Cooper GS. Severity-adjusted mortality and length of stay in teaching and
nonteaching hospitals. Results of a regional study. JAMA. Aug 13
1997;278(6):485-490. Woods AW, MacKirdy FN, Livingston BM, Norrie J, Howie JC.
Evaluation of predicted and actual length of stay in 22 Scottish intensive care
units using the APACHE III system. Acute Physiology and Chronic Health
Evaluation. Anesthesia. Nov 2000;55(11):1058-1065. Glance LG, Osler TM, Dick
AW. Identifying quality outliers in a large, multiple-institution database by
using customized versions of the Simplified Acute Physiology Score II and the
Mortality Probability Model II0. Crit Care Med. Sep 2002;30(9):1995-2002.
Markgraf R, Deutschinoff G, Pientka L, Scholten T, Lorenz C. Performance of the
score systems Acute Physiology and Chronic Health Evaluation II and III at an
interdisciplinary intensive care unit, after customization. Crit Care.
2001;5(1):31-36. Murphy-Filkins R, Teres D, Lemeshow S, Hosmer DW. Effect of
changing patient mix on the performance of an intensive care unit
severity-of-illness model: how to
| Participation in a Patient Safety Culture Survey for program(s): IQR (MUC ID: X3689) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support. This measure should be quickly replaced with a measure assessing results of a survey of a culture of patient safety. ?
Does the measure address a critical program objective as defined by MAP? Yes. This measure could begin to address the gap around promoting a culture of safety.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.No, this is a structural measure that will provide information on whether or not a hospital participates in a patient safety culture survey.Move towards more outcome measures rather than structure or process measures.No, this is a structural measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. N/AEngage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure could begin to address the gap around promoting a culture of safety.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? No. Testing information was not available for this measure.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. No. This measure is not currently being used in any federal or private programs.
Does the measure promote alignment and parsimony? Yes. This measure could be a first step towards assessing a patient safety culture. However, an assessment of participation in a survey should only be used as a short-term interim step and this measure should be quickly replaced with a measure assessing the results of a survey of patient safety culture.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: A Patient Safety Culture Survey
is TJC element of performance. Making care safer is a priority for CMS and as
such is one of the CMS quality goals. One way to implement this goal would be to
create a patient safety culture assessment measure. This structural measure
will allow us to gain an understanding of the patient safety culture assessment
landscape without adding undue reporting burden to hospitals. Safety culture
surveys are useful for measuring organizational conditions that can lead to
adverse events and patient harm in healthcare organizations. They can be used
to: ¦raise staff awareness about patient safety ¦diagnose and assess the current
status of patient safety culture ¦identify strengths and areas for improvement
¦examine trends in patient safety culture and trends overtime
| Patient fall rate for program(s): IQR (MUC ID: E0141) |
NQF Number (if applicable): 0141
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending demonstration of applicability at the facility level and resolution of the duplicative nature of this measure with the falls and trauma component of PSI-90.Rationale: Falls are a common adverse event in hospitals, with estimates of between 2-5 falls per 1,000 patient days. About 30% of falls result in injury, disability, or death. While falls and trauma are currently addressed in the IQR program in the PSI-90 composite measure, MAP has previously noted that NQF #0141 and #0202 are based off of clinical data and may provide better data than claims-based measures.
Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses falls, a critical patient safety issue for inpatient settings. Although falls are currently measured through PSI-90, this measure has been preferred by MAP in the past.Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, falls are one of the most common causes of patient harm in hospitals. ?Move towards more outcome measures rather than structure or process measures.?Yes, this is an outcome measure.?Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.?No?Engage patients and families as partners in their care.N/A?Expand the program to include measures that allow rural and other small hospitals to participate.?N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, while falls and trauma are currently addressed in the IQR program in the PSI-90 composite measure, MAP has previously noted that NQF #0141 and #0202 are based off of clinical data and may provide better data than claims-based measures. Falls are a common adverse event in hospitals, with estimates of between 2-5 falls per 1,000 patient days.About 30% of falls result in injury, disability, or death. This measure is paired with NQF #0202.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? No. This measure has been tested at the clinician level of analysis. More information is needed on how this would be applied at the facility level.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. This measure has been tested at the clinician level of analysis.
Is the measure currently in use? Yes. This measure is currently in use in private programs such as NDNQI, Colorado Hospital Report Card, Massachusetts Public Reporting, and the Norton National Healthcare Public Reporting Program.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is part of the MAP Safety Family of Measures and the MAP Dual Eligible Beneficiaries Family of Measures. This measure also captures a broad population and only excludes pediatrics, psychiatric unit, and obstetrical unit of patients. This is a high value outcome measure that addresses an important safety area. However, falls are currently addressed in the PSI-90 composite included in the IQR measure set. This measure may provide more accurate data but that may need to be balanced with parsimony concerns of adding differing methodologies to the same program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is NQF #0202 – Falls with Injury?
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: The measure focus addresses
several national health goals and priorities, for example: 1. Recently enacted
Centers for Medicare and Medicaid Services regulations limit hospital
reimbursement for care related to fall related injuries. 2. The falls measures
fits within the priorities set forth by the National Priorities Parternship.
Specifically, it fits within the national priority of Making Care Safer
(National Priorities Partnership, 2011). 3. As part of their National Patient
Safety Goals, The Joint Commission requires hospitals to reduce the risk of
patient harm resulting falls and to implement a falls reduction program. Other
evidence: Falls are one of the most common inpatient adverse events, with
estimates of between 2 and 5 falls per 1,000 patient days (Agostini, Baker,
& Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et al., 2002,
2008). In quarter 3 of 2009, fall rates for nursing units in participating NDNQI
hospitals averaged 3.2 per 1000 patient days (median = 2.8 per 1000 patient
days). About 30% of falls result in injury disability or death (Shorr, 2008) –
particularly in older adults. Injury falls lead to as much as a 61% increase in
patient-care costs and lengthen a patient’s hospital stay (Fitzpatrick, 2011).
Jorgensen (2011) estimated that by 2020 the direct and indirect costs of
injuries related to falls will reach $54.9 billion. In addition injury falls are
a significant source of liability for hospitals. Agnostini, J.V., Baker, D.I.,
& Bogardus, S.T. (2001). Prevention of falls in hospitalized and
institutionalized older people. In Making health care safer: A critical analysis
of patient safety practices (pp.281-299). Evidence Report/Technology Assessment
Number 43, AHRQ publication No. 01-E058. Rockville, MD: Agency for Healthcare
Research and Quality. Fitzpatrick, M.A. (2011, March).Meeting the challenge of
fall reduction [Supplement]. American Nurse Today, p. 1. Jorgensen, J. (2011,
March). Reducing patient falls: A call to action [Supplement]. American Nurse
Today, p. 2-3. National Priorities Partnership. (2011, September). Input to the
Secretary of Health and Human Services on Priorities for the National Quality
Strategy. Retrieved from: http://www.qualityforum.org/Home.aspx Oliver, D.,
Connelly, J.B., Victor, C.R. et al. (2007). Strategies to prevent falls and
fractures in hospitals and care homes and effect of cognitive impairment. 384,
82. Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use, restrain
orders, and the risk of falls in hospitalized patients. Journal of the American
Geriatric Society, 50, 526-529. Shorr, R.I., Mion, L.C., Chandler, M., et al.
(2008). Improving the capture of fall events in hospitals: Combining a service
for evaluating inpatient falls with an incident report system. Journal of the
American Geriatric Society, 56, 701-704. Unruh, L. (2002). Tends in adverse
events in hospitalized patients. Journal of Healthcare Quality, 24, 4-10.
| Patient Information for program(s): OQR (MUC ID: E0294) |
NQF Number (if applicable): 0294
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the patient information, which includes the patient’s name, address, date of birth, gender, significant other contact information, and health insurance information was communicated to the receiving facility within 60 minutes of departure.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare.Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patients who are transferred
from an Emergency Department to another acute facility are excluded from the
calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD 2006,
Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).
Communication problems are a major contributing factor to adverse events in
hospitals, accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care physicians in
the community (Kripalani S 2007), and between hospitals and long term facilities
(Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal
#2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement
2E for this goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician hand-offs
from the emergency department to inpatient units, other hospitals, and other
types of health care facilities. The process must include a method of
communicating up-to-date information regarding the patient’s care, treatment and
services, condition and any recent or anticipated changes (JCAHO-2 2007). 1.
Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in
Hospitalized Patients. Results of the Harvard Medical Practice Study II. New
England Journal of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D.,
Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in
Utah and Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments. Academic
Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C.
and Reese, C. Emergency Department Performance Measures and Benchmarking Summit.
Academic Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell
KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care
hospital emergency departments. . Academic Emergency Medicine 13:746-754, 2006.
6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
hospitals in Kansas. Journal of Rural Health. 20:363-367, 2004. 8. Baldwin LM,
MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in
rural and urban US hospitals. Journal of Rural Health, 20:99-108, 2004. 9.
Westfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest
pain in rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at: http://www.jointcommission.org/SentinelEvents
/Statistics/. Accessed July 18, 2007. 11. Kripalani, S., LeFevre, F., Phillips,
C. et al. Deficits in Communication and Information Transfer between
Hospital-Based and Primary Care Physicians: Implications for Patient Safety and
Continuity of Care. JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and
Fitzpatrick J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004.
| Payment-Standardized Medicare Spending Per Beneficiary (MSPB) for program(s): MSSP (MUC ID: E2158) |
NQF Number (if applicable): 2158
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Support
Preliminary analysis summary: This cost/resource measure captures services deliveredbetween 3 days prior to an acute inpatient hospital admission through the period 30 days after discharge. As aMAP identified high-value measurement area, this measure seeks incentive hospitals to improve care coordination and reduce fragmentation across the health care delivery system. The measure also promotes alignment across quality measurement reporting programs since it is used in the hospital inpatient quality reporting program, and the hospital value-based purchasing program. This measure is included in the MAP Affordability Family of Measures along with MAP Duals Family of Measures.
Does the measure address a critical program objective as defined by MAP? Yes. This measure would help address costs for Medicare fee-for-service beneficiaries. This cost of care measure when used alongside measures of quality can help to improve the value of healthcare services delivered across health care providers and care settings.fee-for-service beneficiaries. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: N/A This measure captures all part A and part B claims for Medicare fee-for-service beneficiaries. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This cost of care measure when used alongside measures of quality can help to improve the value of healthcare services delivered across health care providers and care settings.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: The MSPB measure seeks to financially incentive hospitals to improve care coordination and reduce fragmentation across the health care delivery system. In particular, this measure encourages hospitals to coordinate with post-acute providers to reduce unnecessary hospital admissions and avoidable readmissions, reduce low-value post-acute services, and help direct patients to the appropriate level of post-acute care. · Promote alignment across other quality measurement reporting programs (e.g., end of life palliative care) ;o Response: This measure promotes alignment across quality measurement reporting programs, including the hospital inpatient quality reporting (IQR) program, and the hospital value-based purchasing (VBP) program. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: The MAP identified high-value measures such as those that measure cost and resource use. This cost/resource use measure captures services deliveredbetween 3 days prior to an acute inpatient hospital admission through the period 30 days after discharge.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is current in use in the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing (VBP) programs.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure captures a broad segment of the population by including all Medicare fee-for-service beneficiaries, and promotes alignment across quality measurement reporting programs since it is used in the hospital inpatient quality reporting program, and the hospital value-based purchasing program. This measure is included in the MAP Affordability Family of Measures along with MAP Duals Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: Addresses gap of cost/resource
use and aligns with other quality reporting programs.
| Performing an intraoperative rectal examination at the time of prolapse repair for program(s): MSSP (MUC ID: X3740) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Do not support
Preliminary analysis summary: This process measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.
Does the measure address a critical program objective as defined by MAP? Yes. This process measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Prolapse repair is a common procedure with 100,000 to 200,000 surgeries performed per year; however it does not address the overall health of the Medicare population. In addition to impacting a large number of individuals, the cost of treatment and rate of complications are high[i].[i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not address care delivered across providers in multiple care settings.· Promote alignment across other quality measurement reporting programs (e.g., end of life palliative care) ;· Response: N/A· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: The measure does not address any of the high-value measure domains identified by the MAP for the Medicare Shared Savings Program.[i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No. This measure is not currently in use in any federal or private programs. However, it is being considered for multiple PQRS-based programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, and the Physician Value Based Payment Modifier Program.
Does the measure promote alignment and parsimony? No. This measure does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Rectal injuries occur with
surgery for pelvic organ prolapse involving the posterior and apical vaginal
compartments. Correcting such injuries at the time they occur is preferable over
delayed recognition due to an increase in morbidity and the need for additional
surgery. Therefore, performing and documenting a rectal examination during the
surgery would help identify such rectal injury in a timely manner and would
potentially increase the safety in performing such surgeries.
| Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury for program(s): MSSP (MUC ID: X3752) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This is an important measure to detect urinary tract injury which is a common complication of this type of surgery.
Does the measure address a critical program objective as defined by MAP? Yes. Lower urinary tract injury is a common complication of this type of surgery.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i],[ii]. Lower urinary tract injury is a common complication of this type of surgery. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: The measure does not address care delivered across care settings or providers. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: N/A· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure does not address any of the high-value measurement domains identified for the Medicare Shared Savings program.[i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.[ii] Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Lower urinary tract (bladder
and/or ureter(s)) injury is a common complication of prolapse repair surgery,
occurring in up to 5% of patients. Delay in detection of lower urinary tract
injury has an estimated cost of $54, 000 per injury (Visco et al), with
significant morbidity for patients who experience them. Universal cystoscopy may
detect up to 97% of all injuries at the time of surgery (Ibeanu et al, 2009),
resulting in the prevention of significant morbidity and providing significant
cost savings (over $108 million per year) In a recent study we found that 84.5%
(539/638) performed cystoscopy 97% of high volume surgeons performed a
cystoscopy at the time of hysterectomy for pelvic organ prolapse while low
volume surgeons performed this procedure only 75 % of the time (p<.001).
| Perinatal Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in vertex position delivered by cesarean section for program(s): IQR (MUC ID: X1970) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This maternal/child health disparities sensitive outcome measure is included in the MAP Safety Family of Measures and also under review for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program.
Does the measure address a critical program objective as defined by MAP? Yes. This maternal/child health outcome measure, which is also under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals, focuses on cesarean sections performed on first time mothers, who have poorer outcomes when labor is forced before the cervix is ready. This measure is part of a five measure nationally implemented perinatal care measure set (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding).Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers. Evidence shows over 60% of variation within healthcare institutions when it comes to cesarean outcomes can be attributed to first birth labor induction rates and early labor admission rates, the outcomes of which were often poorerMove towards more outcome measures rather than structure or process measures. Outcome measureAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. Under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access HospitalsEngage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. This measure fills a gap for maternal/child health In 2013-14 Pre-Rulemaking, this measure was on the MUC list and the MAP Hospital Workgroup supported it for inclusion in the Inpatient Hospital Quality Reporting program with these comments: MAP noted that there is an important public education piece to the reporting of PC-02 and recommended that CMS work with others to ensure consumers understand what the results mean and why the measure is important.?
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. While the claims and paper records version of this measure is NQF-endorsed (0471 – PC-02 Cesarean Section), the measure is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? . As a disparities sensitive outcome measure that is included in the MAP Safety Family of Measures and also under review for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program, this measure contributes to the efficient use of measurement resources and supports alignment across programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: PC O2 is newly specified for
electronic health records. Rationale: The removal of any pressure to not
perform a cesarean birth has led to a skyrocketing of hospital, state and
national cesarean section (CS) rates. Some hospitals now have CS rates over 50%.
Hospitals with CS rates at 15-20% have infant outcomes that are just as good and
better maternal outcomes (Gould et al., 2004). There are no data that higher
rates improve any outcomes, yet the CS rates continue to rise. This measure
seeks to focus attention on the most variable portion of the CS epidemic, the
term labor CS in nulliparous women. This population segment accounts for the
large majority of the variable portion of the CS rate, and is the area most
affected by subjectivity. As compared to other CS measures, what is different
about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear
cut quality improvement activities that can be done to address the differences.
Main et al. (2006) found that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor
admission rates. The results showed if labor was forced when the cervix was not
ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor
and delivery guidelines can make a difference in labor outcomes. Many authors
have shown that physician factors, rather than patient characteristics or
obstetric diagnoses are the major driver for the difference in rates within a
hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The
dramatic variation in NTSV rates seen in all populations studied is striking
according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008;
California Office of Statewide Hospital Planning and Development [OSHPD], 2007)
and physicians within a hospital (Main, 1999) have rates with a 3-5 fold
variation. Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html.
| Perinatal Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in vertex position delivered by cesarean section for program(s): MUHCAH (MUC ID: X1970) |
NQF Number (if applicable):
Programs under consideration: Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs)
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: While the claims and paper records version of this disparities sensitive outcome measure that is included in the MAP Safety Family of Measures and also under review for the Hospital Inpatient Quality Reporting program measure isNQF-endorsed (0471 – PC-02 Cesarean Section), the measure is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Does the measure address a critical program objective as defined by MAP? Yes. This measure focuses on an important safety issue for cesarean sections performed on first time mothers. Poorer outcomes have been noted when labor is forced before the cervix is ready. Theclaims and paper records version of this maternal/child health outcome measure(0471 – PC-02 Cesarean Section)isNQF-endorsed and also under review for the Hospital Inpatient Quality Reporting program. This measure is partof a five measure nationally implemented perinatal care measure set (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding).Critical Objectives:Preference should be given to NQF-endorsed quality measures.Theclaims and paper records version of this maternal/child health outcome measure(0471 – PC-02 Cesarean Section)isNQF-endorsed.Select measures that represent the future of measurement (facilitating information exchange between institutions and longitudinal tracking of care, such as measures that monitor incremental changes in a patient’s condition over time). N/AAlign the measure set with other hospital performance measurement programs. Under review for Hospital Inpatient Quality ReportingEnsure e-measures in the program are reliable and provide comparable results to paper-based measures. N/A
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. Needs Implementation Testing
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. As a disparities sensitive outcome measure that is included in the MAP Safety Family of Measures and also under review for the Hospital Inpatient Quality Reporting program, this measure contributes to the efficient use of measurement resources and supports alignment across programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. While the claims and paper records version of this measure isNQF-endorsed (0471 – PC-02 Cesarean Section), the measure is not fully specified as an e-Measure and has not been reviewed as an e-Measure for endorsement.
Rationale for measure provided by HHS: PC O2 is newly specified for
electronic health records. Rationale: The removal of any pressure to not
perform a cesarean birth has led to a skyrocketing of hospital, state and
national cesarean section (CS) rates. Some hospitals now have CS rates over 50%.
Hospitals with CS rates at 15-20% have infant outcomes that are just as good and
better maternal outcomes (Gould et al., 2004). There are no data that higher
rates improve any outcomes, yet the CS rates continue to rise. This measure
seeks to focus attention on the most variable portion of the CS epidemic, the
term labor CS in nulliparous women. This population segment accounts for the
large majority of the variable portion of the CS rate, and is the area most
affected by subjectivity. As compared to other CS measures, what is different
about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear
cut quality improvement activities that can be done to address the differences.
Main et al. (2006) found that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor
admission rates. The results showed if labor was forced when the cervix was not
ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor
and delivery guidelines can make a difference in labor outcomes. Many authors
have shown that physician factors, rather than patient characteristics or
obstetric diagnoses are the major driver for the difference in rates within a
hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The
dramatic variation in NTSV rates seen in all populations studied is striking
according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008;
California Office of Statewide Hospital Planning and Development [OSHPD], 2007)
and physicians within a hospital (Main, 1999) have rates with a 3-5 fold
variation. Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html.
| Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy for program(s): MSSP (MUC ID: E0465) |
NQF Number (if applicable): 0465
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Support
Preliminary analysis summary: This fully developed and tested endorsed measure assessesaddresses the safety of patients by evaluatingappropriate use of medications before and after procedure. It also requires a level of coordination and collaboration within ACO.
Does the measure address a critical program objective as defined by MAP? Yes. This measure does not address any of the critical program objectives or identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.§ Yes, this measure addresses the safety of patients undergoing Carotid Endarterectomy, which is a high risk procedure for the Medicare population. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure addresses the safety ofpatients undergoing Carotid Endarterectomy, which is a high risk procedure for the Medicare population. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure does not directly address the rate of growth of health care spending.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not measure care across settings of care or providers. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure does not promote alignment across quality measurement programs since it is currently not in use. The measure is under consideration in PQRS-based programs.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response:This process measure does not address the high-value measurement domains identified by the MAP.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No. No. This measure is not currently in use in any federal or private programs. It is under consideration for use in PQRS-based programs, including: Physician Compare, Physician Feedback/Quality and Resource utilization Reports, and Physician Value Based Payment Modifier Program.
Does the measure promote alignment and parsimony? Yes. This measure has the potential to promote alignment since the measure is currently under review for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: The Vascular Study Group of
Northern New England (VSGNNE) has published validated registry data from 48
surgeons in 9 hospitals concerning more than 3000 patients undergoing CEA
(Cronenwett, 2007). This demonstrated initially that only 82% of patients were
taking ASA or clopidogrel preoperatively before CEA in 2004. Through quality
improvement efforts, this percentage has increased to 91% during the first 6
months of 2007. Further, a recent study from Austria found that 37% of 206
patients undergoing CEA were not on preoperative antiplatelet therapy, and
concluded that this practice does not meet current guidelines and provides
substantial opportunity for improvement (Assadian, 2006).
| Perioperative Temperature Management for program(s): MSSP (MUC ID: X3809) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Do not encourage further consideration
Preliminary analysis summary: This measure has been retired by the measure steward, CMS.
Does the measure address a critical program objective as defined by MAP? No. Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: N/A· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not address care across settings or providers· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure does not address the high value measurement domains identified by MAP for the Medicare Shared Savings Program.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? No. This measure has been retired by CMS, the measure steward. Continued use of this measure would not support an efficient use of measurement resources.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: A drop in core temperature
during surgery, known as perioperative hypothermia, can result in numerous
adverse effects, which can include adverse myocardial outcomes, subcutaneous
vasoconstriction, increased incidence of surgical site infection, and impaired
healing of wounds. The desired outcome, reduction in adverse surgical effects
due to perioperative hypothermia, is affected by maintenance of normothermia
during surgery.
| Physician Information for program(s): OQR (MUC ID: E0295) |
NQF Number (if applicable): 0295
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set, which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the physician information, which includes physician or practitioner gathered history, physical results, orders and plan, was communicated to the receiving facility within 60 minutes of departure. Critical Objectives: Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patients who are transferred
from an Emergency Department to another acute facility are excluded from the
calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD 2006,
Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).
Communication problems are a major contributing factor to adverse events in
hospitals, accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care physicians in
the community (Kripalani S 2007), and between hospitals and long term facilities
(Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal
#2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement
2E for this goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician hand-offs
from the emergency department to inpatient units, other hospitals, and other
types of health care facilities. The process must include a method of
communicating up-to-date information regarding the patient’s care, treatment and
services, condition and any recent or anticipated changes (JCAHO-2 2007). 1.
Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in
Hospitalized Patients. Results of the Harvard Medical Practice Study II. New
England Journal of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D.,
Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in
Utah and Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments. Academic
Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C.
and Reese, C. Emergency Department Performance Measures and Benchmarking Summit.
Academic Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell
KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care
hospital emergency departments. . Academic Emergency Medicine 13:746-754, 2006.
6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
hospitals in Kansas. Journal of Rural Health. 20:363-367, 2004. 8. Baldwin LM,
MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in
rural and urban US hospitals. Journal of Rural Health, 20:99-108, 2004. 9.
Westfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest
pain in rural hospitals: Implementation of the ACI-TIPI in the High Plains
Research Network. Annals of Family Medicine. 4:153-158, 2006. 10. Joint
Commission on Accreditation of Healthcare Organizations. Sentinel Events
Statistics. Available at: http://www.jointcommission.org/SentinelEvents
/Statistics/. Accessed July 18, 2007. 11. Kripalani, S., LeFevre, F., Phillips,
C. et al. Deficits in Communication and Information Transfer between
Hospital-Based and Primary Care Physicians: Implications for Patient Safety and
Continuity of Care. JAMA 297(8):831-841, 2007. 12. Cortes T., Wexler S. and
Fitzpatrick J. The transition of elderly patients between hospitals and nursing
homes. Improving nurse-to-nurse communication. Journal of Gerontological
Nursing. 30(6):10-5, 2004.
| Post breast conservation surgery irradiation for program(s): PCHQR (MUC ID: E0219) |
NQF Number (if applicable): 0219
Programs under consideration: PPS-Exempt Cancer Hospital Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure addresses the critical program objectives of PPS-Exempt Cancer HQRP, has been tested for th appropriate level of analysis, is NQF endorsed, and supports alignment across programs.
Does the measure address a critical program objective as defined by MAP? Yes. Include measures appropriate to cancer hospitals that reflect the highest priority services provided by these hospitals. Breast cancer is the second most common type of cancer and is the second most common cause of cancer death for women in the United States.[i] Breast-conserving surgery removes the cancer but not the breast itself[ii]. Breast-conserving therapy should involve breast-conserving surgery plus radiation therapy[iii] however, when evaluating this measure the NQF Cancer Endorsement Maintenance Steering Committee found variation in the use of radiation for women who had breast-conserving surgery[iv]. Align measures with the Inpatient Quality Reporting Program and Outpatient Quality Reporting Program where appropriate and relevant. N/AThe measures should address gaps in cancer care quality. MAP has previously identified pain screening and management, patient and family/caregiver experience, patient-reported symptoms and outcomes, survival, shared decision making, cost, care coordination and psychosocial/supportive services as gap areas for this programWhile this measure does not assess survival directly, radiation therapy following breast conserving surgery is associated with a lower risk of recurrence and mortality[v]. [i] 2014 UptoDate. Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer. [ii] http://www.cancer.gov/dictionary?cdrid=45626[iii] http://www.uptodate.com/contents/overview-of-the-treatment-of-newly-diagnosed-non-metastatic-breast-cancer?source=search_result&search=breast+cancer+breast-conserving+surgery&selectedTitle=1~150[iv] NQF Cancer Endorsement Maintenance 2011. Final Report. [v] http://www.cancer.gov/clinicaltrials/results/summary/2011/EBCTCG1211
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The measure has been tested for hospital/acute care facilities.
Is the measure currently in use? Yes. Yes,this measure is used by the American College of Surgeons’ Commission on Cancer. The measure has been in use by the Commission on Cancer since 2007.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes, ?the measure is not duplicative of another measure in the PCHQR program. While this measure is not used in another federal program, it is part of the MAP Cancer Family of Measures. This measure would fill a gap in breast cancer care previously identified by the Hospital workgroup.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is an endorsed measure (#0219).
Rationale for measure provided by HHS: CoC-accredited (Commission on
Cancer) facilities have the ability to submit this data. Measure is already
NQF-endorsed. There is an extensive literature demonstrating variations in the
use of radiation with breast conservation surgery based on factors including
age, race/ethnicity, socioeconomic status, location of treatment, provider,
tumor characteristics, and other factors. Daroui P, Gabel M, Khan AJ, Haffty BG,
Goyal S. Utilization of breast conserving therapy in Stage 0, I, and II breast
cancer patients in New Jersey: An American College of Surgeons National Cancer
Data Base (NCDB) Analysis. Am J Clin Oncol 2011; Feb 15(epub ahead of print). 2.
Smith Gl, Shih YC, Xu Y, et al. Racial disparities in the use of radiotherpay
after breast conserving surgery: a national Medicare study. Cancer
2010;11:734-741. 3. Bickell NA, Wang JJ, Oluwole S, et al. Missed opportunities:
racial disparities in adjuvant breast cancer treatment. J Clin Oncol
2006;24:1357-1362.
| Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) for program(s): MSSP (MUC ID: X3810) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU). The measure does encourage coordination within an acute care facility among providers. The measure does have the potential to improve surgical and anesthesia care for the Medicare population.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: While this measure does not address the overall health of the Medicare FFS population, it does focus on a subset of beneficiaries who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU).· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure does not directly address the growth rate of healthcare spending.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: While this measure does encourage coordination within an acute care facility among providers, it doesn’t address care across settings. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is being considered for PQRS-based programs.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure does not address the high-value measure domains identified by the MAP for MSSP.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Peri-procedure transitions of
care place patients at risk for incomplete sharing of important information
between practitioners. Effective communication between providers at the time of
admission to PACU promotes safe care and enhances coordination of care.
| Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) for program(s): MSSP (MUC ID: X3807) |
NQF Number (if applicable): N/A
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure addresses a subset of beneficiaries who have been cared for in the OR and are transferred to the ICU andencourages coordination within an acute care facility among providers. The measure also has the potential to improve surgical and anesthesia care for the Medicare population.
Does the measure address a critical program objective as defined by MAP? Yes. This measure has the potential to improve coordination and care improvement from the OR to the ICU. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure focuses on patients who undergoprocedure under anesthesia and are admitted to an Intensive Care Unit (ICU). · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure does not directly address the growth rate of healthcare spending.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: While this measure encourages coordination across multiple points of care within the hospital, it does not span across care settings or providers.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care);· Response: This measure is being considered for other PQRS-based programs.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure does not address the MAP identified high-value measurement areas or gaps for this program.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? Yes. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: A uniform transfer of care
protocol or handoff tool/checklist that is utilized for all patients directly
admitted to the ICU after undergoing a procedure under the care of an anesthesia
practitioner will facilitate effective communications between the medical
practitioner who provided anesthesia during the procedure and the care
practitioner in the ICU who is responsible for post-procedural care. This should
minimize errors and oversights in medical care of ICU patients after procedures.
Hand-offs of care are a vulnerable moment for patient safety, but required in
any 24/7 healthcare system. Anesthesia providers routinely transfer critically
ill patients from the OR to the ICU, and are responsible for transmitting
knowledge about patient history, a summary of intraoperative events, and future
plans for hemodynamic and pain management to the ICU team. Evidence demonstrates
that this process can be facilitated by use of a checklist that motivates
completion of all key components of the transfer. This is an emerging best
practice in anesthesia care.
| Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents for program(s): MSSP (MUC ID: X3808) |
NQF Number (if applicable): N/A
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Do not encourage further consideration
Preliminary analysis summary: While an important clinical measure, it does not address identified gaps for the Medicare Shared Savings Program, nor does it encourage coordination and shared accountability across all settings that patients receive care.
Does the measure address a critical program objective as defined by MAP? Yes. This process measure is an important preventive service; however, this measure does not encourage coordination or shared accountability across settings, providers, or time. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure addresses an important preventive process for beneficiaries who may have a complication from a stent placement. Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: The measure does not address care delivered across care settings and providers.· Promote alignment across other quality measurement reporting programs (e.g., end of life palliative care);· Response: No.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: The measure does not address the high-value measurement domains identified by the MAP for the Medicare Shared Savings Program.
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? No. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Late stent thrombosis is a
relatively rare but serious complication of stent placement, with an estimated
case fatality rate of up to 45%. Multiple studies have shown that premature
discontinuation of dual antiplatelet therapy is associated with increased risk
of stent thrombosis in patients with drug-eluting stents. Late stent thrombosis,
or thrombosis >1 year after stent placement, is of particular concern for
drug-eluting stents. This concern indicates a need for a longer course of dual
antiplatelet therapy for patients with drug-eluting stents compared to those
with bare metal stents.
| Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination for program(s): MSSP (MUC ID: X3806) |
NQF Number (if applicable): N/A
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This measure addresses an important area for potential surgical care improvement for Medicare beneficiaries.
Does the measure address a critical program objective as defined by MAP? Yes. This measure seeks to improve the health of a specific segment of the Medicare FFS population, specifically thosewho undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.§ Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;o Response: This measure seeks to improve the health of a specific segment of the Medicare FFS population, specifically thosewho undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure does not address the rate of growth in health care spending.· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not address care across settings.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care);· Response: This measure does promote alignment across PQRS-based programs.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This measure does not address the high value measurement areas identified by the MAP. There is insufficient evidence that assessment of nausea and vomiting is associated with fewer postoperative complications; however, is a standard of care that should be done during recovery[i].[i] https://www.asahq.org/For-Members/Practice-Management/~/media/For%20Members/Practice%20Management/PracticeParameters/2013/Practice%20Guidelines%20for%20Postanesthetic%20Care%202013.ashx
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. The measure is currently under development and testing has not been completed. The measure is being considered for all of the PQRS-based programs; including PQRS, Physician Compare, Physician Feedback/Quality and Resource Use Utilization Reports, and the Physician Value-Based Payment Modifier Program
Does the measure promote alignment and parsimony? Yes. The measure has the potential to promote alignment across programs by being under consideration for multiple programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Postoperative nausea and
vomiting (PONV) is an important patient-centered outcome of anesthesia care.
PONV is highly dis-satisfying 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. 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.
| Procedures and Tests for program(s): OQR (MUC ID: E0297) |
NQF Number (if applicable): 0297
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set, which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the that procedure and test information, which includes information on any tests and/or procedures done and their results, was communicated to the receiving facility within 60 minutes of departure.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare.Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module. Response: Yes, enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patients who are transferred
from an Emergency Department to another acute facility are excluded from the
calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD 2006,
Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).
Communication problems are a major contributing factor to adverse events in
hospitals, accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care physicians in
the community (Kripalani S 2007), and between hospitals and long term facilities
(Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal
#2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement
2E for this goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician hand-offs
from the emergency department to inpatient units, other hospitals, and other
types of health care facilities. The process must include a method of
communicating up-to-date information regarding the patient’s care, treatment and
services, condition and any recent or anticipated changes (JCAHO-2 2007). 1.
Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in
Hospitalized Patients. Results of the Harvard Medical Practice Study II. New
England Journal of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D.,
Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in
Utah and Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments. Academic
Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C.
and Reese, C. Emergency Department Performance Measures and Benchmarking Summit.
Academic Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell
KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care
hospital emergency departments. . Academic Emergency Medicine 13:746-754, 2006.
6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
hospitals in Kansas. Journal of Rural Health. 20:363-367, 2004.
| Proportion of Patients Hospitalized with AMI that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) for program(s): IQR (MUC ID: E0704) |
NQF Number (if applicable): 0704
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: This measure addresses a number of adverse outcomes that are meaningful to patients and can increase costs across the system. This measure received conditional support pending NQF review of the testing data in a Medicare population and resolution of parsimony concerns with measures currently in the IQR program.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, this measure addresses a number of complications that are meaningful to consumers. Additionally potentially avoidable complications are associated with higher costs and waste.Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measureAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is in use in a number of payroll, accounting, and HR systems as well as a number of quality programs.Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. No, this measure addresses a number of potentially avoidable complications such readmissions and safety events. However, these complications are currently covered by other measures in the program and were not named as gaps.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes. This measure has been tested at the appropriate care setting and level of analysis. However, these measures should be reviewed by NQF for testing in the Medicare population.
Is the measure currently in use? Yes. Yes. This measure is currently being used in Prometheus
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes. This measure is part of the MAP Care Coordination Family of Measures, captures a broad population of patients 18-65 years old, and addresses important safety concerns. However, many of the conditions addressed in this measure are currently addressed by other measures in the IQR program. The value add of this measure should be balanced with parsimony concerns of adding differing methodologies to the same program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes. NQF# 0704 – Measure undergoing endorsement maintenance, Cardiovascular Measures 2015.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
Rationale for measure provided by HHS: High priority aspect of
healthcare: Acute Myocardial Infarction (AMI) is a common cause of
hospitalization and the initial cost of treatment of AMI has been estimated to
begin at approximately $10,000. However, due to considerable variability in
costs of care of typical AMI patients, the average costs per patient is close to
$15,000. Extrapolated to the more than 200,000 Medicare beneficiaries who are
annually hospitalized with AMI, the costs related to initial hospitalizations
from AMI could be upwards of $3 billion. Moreover, when AMI admissions incur
potentially avoidable complications, these costs can go up several fold and are
truly a waste within the healthcare system."
| Proportion of Patients Hospitalized with Pneumonia that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) for program(s): IQR (MUC ID: E0708) |
NQF Number (if applicable): 0708
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: This measure addresses a number of adverse outcomes that are meaningful to patients and can increase costs across the system. This measure has received conditional support pending NQF review of the testing data in a Medicare population and resolution of parsimony concerns with measures currently in the IQR program.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, this measure addresses a number of complications that are meaningful to consumers. Additionally potentially avoidable complications are associated with higher costs and waste.Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measureAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is in use in a number of payroll, accounting, and HR systems as well as a number of quality programs.Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. No, this measure addresses a number of potentially avoidable complications such readmissions and safety events. However, these complications are currently covered by other measures in the program and were not named as gaps.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the appropriate care setting and level of analysis. However, these measures should be reviewed by NQF for testing in the Medicare population.
Is the measure currently in use? Yes. Yes. This measure is currently being used in Prometheus
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes. This measure is part of the MAP Care Coordination Family of Measures, captures a broad population of patients 18-65 years old, and addresses important safety concerns. However, many of the conditions addressed in this measure are currently addressed by other measures in the IQR program. The value add of this measure should be balanced with parsimony concerns of adding differing methodologies to the same program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF# 0708 – Measure undergoing endorsement maintenance, Cardiovascular Measures 2015.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
Rationale for measure provided by HHS: A study from the Boston Medical
Center, Boston MA, demonstrated that although one in five hospitalizations are
complicated by post-discharge adverse events, development of a strong discharge
services program for patients admitted for medical conditions reduced hospital
utilization within 30 days of discharge. Umscheid et al used 2002 estimates of
hospital-acquired infections (HAI) and determined the range of HAI risk
reductions from US studies. They report that 18%-82% of blood-stream infections,
46%-55% of ventilator associated pneumonia, 17% - 69% of urinary tract
infections and 26%-54% of surgical site infections are preventable. Healy et al
analyzed complications in hospitalized surgical patients and reported that
between 39% and 61% of major complications (wound infections, pneumonia, urinary
tract infections, arrhythmias, respiratory failure, gastrointestinal
complications, deep vein thrombosis) and about an equal percent of minor
complications could have been avoided. The National Pressure Ulcer Advisory
Panel (NPUAP) reported in 2001 that pressure ulcer prevention programs had
reported 50% or greater reductions in facility-acquired pressure ulcers.
Similarly, appropriate prophylaxis could reduce the risk of venous
thromboembolism by 45% in acutely ill medical patients, and a recent study found
a 50% reduction in thromboembolic events with extended pharmacologic
prophylaxis. Adequate evidence-based treatment protocols in preventing contrast
nephropathy and adequate drug dosing have demonstrated a risk reduction between
52% and 90% in the incidence of acute renal failure in patients in the intensive
care unit. Additionally, use of electronic medical systems has demonstrated that
in a sample hospital that used prompts for protocols for nursing care, infection
rates dropped 88%, bedsores were reduced and compliance to guidelines for care
of patients on ventilator increased by 77%.
| Proportion of Patients Hospitalized with Stroke that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) for program(s): IQR (MUC ID: E0705) |
NQF Number (if applicable): 0705
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: This measure addresses a number of adverse outcomes that are meaningful to patients and can increase costs across the system.Conditional support pending NQF review of the testing data in a Medicare population and resolution of parsimony concerns with measures currently in the IQR program.
Does the measure address a critical program objective as defined by MAP? Yes. Critical Program ObjectivesChoose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, this measure addresses a number of complications that are meaningful to consumers. Additionally potentially avoidable complications are associated with higher costs and waste.Move towards more outcome measures rather than structure or process measures.Yes, this is an outcome measureAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is in use in a number of payroll, accounting, and HR systems as well as a number of quality programs. Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. No, this measure addresses a number of potentially avoidable complications such readmissions and safety events. However, these complications are currently covered by other measures in the program and were not named as gaps.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Yes. This measure has been tested at the appropriate care setting and level of analysis. However, these measures should be reviewed by NQF for testing in the Medicare population.
Is the measure currently in use? Yes. Yes. This measure is currently being used in Prometheus
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. Yes. This measure is part of the MAP Care Coordination Family of Measures, captures a broad population of patients 18-65 years old, and addresses important safety concerns. However, many of the conditions addressed in this measure are currently addressed by other measures in the IQR program. The value add of this measure should be balanced with parsimony concerns of adding differing methodologies to the same program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes. 0705 – Measure undergoing endorsement maintenance, Cardiovascular Measures 2015.
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: Hospital acquired conditions
(HACs) have been defined by the Centers for Medicare and Medicaid (CMS) under
the proposed rules for 2008 and 2009 and are avoidable conditions in
hospitalized patients. Our potentially avoidable complications (PACs) go beyond
the CMS defined HACs and identify conditions related to the index condition, to
comorbidities that got exacerbated, as well as those related to patient safety
failures. While there is a general understanding of the nature of care failures
during hospitalizations or post-discharge such as readmissions and emergency
room visits, there has been no attempt to measure the magnitude or the type of
potentially avoidable complications, and the cost reductions that would ensue if
a payment model encouraged care to be optimized at benchmarks achieved in
studies. Well-managed patients with stroke should rarely incur a potentially
avoidable complication such as an emergency room visit post-discharge, and
readmissions related to stroke should occur only in the rarest of circumstances.
The enclosed workbook entitled NQF_Stroke_PACs_Risk_Adjustment 2.16.10.xls lists
the types of PACs, their frequency and costs as calculated in our national
database, for both the inpatient stays and readmissions (see tabs
CIP_Index_PAC_Stays and CIP_PAC_Readmissions). The PAC Overview tab shows that
57.8% of all hospitalizations for stroke had a PAC, with 53% of index stays
having a PAC during the initial hospitalization. Of these PACs, over 18.5% were
incurred for direct complications of stroke, another 47% for acute exacerbation
of a comorbidity, and another 34.4% due to patient safety failures such as
sepsis and other widespread infections, complications of surgical procedures,
phlebitis and deep vein thrombosis or CMS-defined hospital acquired conditions.
The primary cause for readmissions and emergency room visits during the 30-day
post-discharge period was due to a hypertensive encephalopathy, diabetic
emergency with hypo- or hyperglycemia, pneumonia or lung complications, or
patient safety failures such as skin or wound infections or sepsis. The ability
to clearly identify the type and frequency of each PAC creates a highly
actionable measure for all providers that are managing or co-managing the
patient, as well as for the health plan with whom the patient is a member.
| Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3743) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This importantoutcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed
Does the measure address a critical program objective as defined by MAP? Yes. This safety-related outcome measure focuses on a common and possibly devastating pelvic surgery complication in the Meducare population. This measure is under review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i]. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: The measure does not address care across setting and providers.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This is an important outcome measure; however was not specifically identified as a high-value area of measurement for the Medicare Shared Savings program by the MAP. [i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and this measure is under review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Bladder injury is a common and
potentially debilitating complication of pelvic surgery but more common in
surgery for pelvic organ prolapse. It is critically important for surgeons who
are performing these procedures to recognize and repair any bladder injury
intraoperatively, in order to minimize postoperative morbidity, including the
need for subsequent surgical intervention to address these complications.
Surgeons who have a higher than expected rate of bladder injury during pelvic
organ prolapse repair would potentially benefit from interventions to improve
the quality of their surgical care.
| Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3744) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This important outcome measure isfully specified and testedand would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed.
Does the measure address a critical program objective as defined by MAP? Yes. This outcome measure focuses on a common and possibly devastating pelvic surgery complication. This measure isunder review for the Medicare Physician Quality Reporting System-based (PQRS) programs including Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: The treatment of pelvic organ prolapse is almost $300 million per year and surgical repair of prolapse is one of the most comment inpatient procedures for women over the age of 70[i]. Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: N/A· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This is an important outcome measure; however was not specifically identified as a high-value area of measurement for the Medicare Shared Savings program by the MAP.[i] Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 202:483.e1.Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and is under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: There are numerous approaches
to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and
robotic. The incidence of visceral injury ranges from 0.1-4% ( SGS Systemic
Review Obstet Gynecol 2008: 112: 1131-1142) depending on the approach with high
potential for morbidity. Unrecognized injury to the intestine increases the risk
of mortality from 2 to 23 % (Chapron et al. J Am Coll Surg. 1991;185:461-465,
Baggish, MS J Gynecol Surg. 2003;19:63-73). It is critically important for
surgeons who are performing these procedures to recognize and repair any
visceral injuries intraoperatively, in order to minimize postoperative
morbidity, including the need for subsequent surgical intervention to address
these complications. Surgeons who have a higher than expected rate of visceral
injury during pelvic organ prolapse repair would potentially benefit from
interventions to improve the quality of their surgical care.
| Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3813) |
NQF Number (if applicable):
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional Support pending NQF review and endorsement. This important outcome measure is fully specified and tested and would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs, however, it is not endorsed.
Does the measure address a critical program objective as defined by MAP? Yes. This outcome measure, which is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program, focuses on ureteral injury, a rare but possibly grave surgery complication for pelvic organ prolapse. · Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: This measure addresses an important area of measurement since prolapse repair is a common procedure with 100,000 to 200,000 surgeries performed per year. In addition to impacting a large number of individuals, the cost of treatment and rate of complications are high[i].· Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: N/A· Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not address care delivered across care settings or multiple providers.· Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure is also under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.· Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.· Response: This is an important outcome measure; however, it does not address high-value domains identified by the MAP for MSSP. [i] http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72617
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. The measure is in use in at least one private program (Australian Council on Healthcare Standards) and is under review for the Medicare Physician Quality Reporting System (PQRS), Physician Compare, Physician Feedback/Quality and Resource Utilization Reports and the Physician Value-Based Payment Modifier Program.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This outcome measure would contribute to the efficient use of measurement resources if it is selected for use across the PQRS-based programs.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Ureteral injury is an uncommon
but potentially serious complication of surgery for pelvic organ prolapse. It is
critically important for surgeons who are performing these procedures to
recognize and repair any ureteral injuries intraoperatively, in order to
minimize postoperative morbidity, including the need for subsequent surgical
intervention to address these complications. Surgeons who have a higher than
expected rate of ureteric injury during pelvic organ prolapse repair would
potentially benefit from interventions to improve the quality of their surgical
care.
| Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract) for program(s): IQR (MUC ID: E0204) |
NQF Number (if applicable): 0204
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Do not support
Preliminary analysis summary: The IQR program currently includes measures that assess the outcomes addressed by nurse staffing levels. MAP has previously noted its desire for the most parsimonious measure sets possible and for outcome measures to be used in place of structural measures when possible. ?
Does the measure address a critical program objective as defined by MAP? Yes. This measure, that focuses on higher levels of nurse staffing which has been found to be associated with better patient outcomes, including shorter length of stay, lower rates of mortality, failure to rescue, hospital acquired infections, medication errors and pressure ulcers, is high impact and is in use in a number of payroll, accounting, and HR systems as well as a number of quality programsCritical Objectives:Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, higher levels of nurses staffing have been found to be associated with better patient outcomes, including shorter length of stay, lower rates of mortality, failure to rescue, hospital acquired infections, medication errors and pressure ulcers. Move towards more outcome measures rather than structure or process measures.No, this is a structural measure.Align reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Yes, this measure is in use in a number of payroll, accounting, and HR systems as well as a number of quality programs.Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. No, nurse staffing was not named as a gap for the IQR program.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested at the facility level.
Is the measure currently in use? Yes. Yes, this measure is currently in use in a number of programs including the Department of Banking, Insurance, Securities and Health Care Administration, the Vermont Hospital Report Card, the Colorado Hospital Report Card Norton Healthcare, Kentucky, and the Maine Health Management Coalition and Maine Quality Forum Publicly Reported Measures.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? No. No, while there is evidence that nurse staffing levels can influence outcomes this is a structural measure and MAP has previously indicated its desire to use outcome measures when possible. The outcomes influenced by nurse staffing are largely addressed by outcome measures currently in the program.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Yes, this is NQF #0204.
Rationale for measure provided by HHS: With the increasing concerns
about cost and quality of patient care over the past 2 decades, hospital nurse
staffing has become a major focus in examining health care workforce
relationships with patient outcomes. Nurses are the largest group of clinical
providers of care in healthcare systems. The Institute of Medicine recently
concluded, in its report, The Future of Nursing: Leading Changing, Advancing
Health (2010), that nurses are vital in providing quality care to patients. A
large body of research has demonstrated that higher nurse staffing levels are
significantly associated with better patient outcomes, including shorter length
of stay and lower rates of mortality, failure to rescue, hospital acquired
infections, falls, medication errors, and pressure ulcers (Blegen, Goode,Spetz,
Vaughn, & Park, 2011; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007;
Lake & Cheung, 2006; Lang, Hodge, Olson, Romano, & Kravitz, 2004;
Lankshear, Sheldon, & Maynard, 2005; Needleman et al., 2011; Stone et al.,
2007; Unruh, 2008). The Agency for Healthcare Research and Quality (AHRQ)
conducted a comprehensive and systematic review of the 97 observational studies
on the relationship between nurse staffing and patient outcomes published
between 1990 and 2006. This AHRQ’s meta-analysis found a strong and consistent
relationship between nurse staffing and specific patient outcomes (mortality and
length of stay), particularly for patients in intensive care units and surgical
units (Kane et al., 2007). For example, length of stay was shorter by 24% in
intensive care units and by 31% in surgical units as 1 RN per patient day was
increased. In addition, nurse staffing affects care costs. There was evidence
that an additional RN hour per patient day or a 10% increase in the proportion
of RNs decreased the odds of patients’ pneumonia by 8.9% or 9.5%, respectively
(Cho, 2003). American Nurses Association (ANA). (2012). ANA’s Principles for
Nurse Staffing, 2nd Edition, Nursebooks.org, Silver Spring, MD. Blegen, M. A.,
Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing
effects on patient outcomes: safety-net and non-safety-net hospitals. Medical
Care, 49(4), 406-414. Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith,
D. G. (2003). The effects of nurse staffing on adverse events, morbidity,
mortality, and medical costs. Nursing Research, 52(2), 71-79. Elliott, M.N.,
Kanouse, D.E., Edwards, C.A., & Hilborne, L.H. (2009). Components of care
vary in importance for overall patient-reported experience by type of
hospitalization. Medicare Care, (47), 842–849. Institute of Medicine. (2011).
The future of nursing: Leading change, advancing health. Wahington, D.C.:
National Academies Press. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval,
S., & Wilt, T. J. (2007). The association of registered nurse staffing
levels and patient outcomes: systematic review and meta-analysis. Medical Care,
45(12), 1195-1204. Kutney-Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P.,
Flynn, L., Neff, D.F., Aiken, L.H. (2009). Nursing: a key to patient
satisfaction. Health Affairs, 28(4). Epub 2009 Jun 12. Lake, E. T., &
Cheung, R. B. (2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse
Staffing? Western Journal of Nursing Research, 28(6), 654-677. Lang, T. A.,
Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L. (2004). Nurse-patient
ratios: a systematic review on the effects of nurse staffing on patient, nurse
employee, and hospital outcomes. Journal of Nursing Administration, 34(7-8),
326-337. Lankshear, A. J., Sheldon, T. A., & Maynard, A. (2005). Nurse
staffing and healthcare outcomes: a systematic review of the international
research evidence. Advances in Nursing Science, 28(2), 163-174. Needleman, J.,
Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M.
(2011). Nurse staffing and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037-1045. Nursing Alliance for Quality Care (NAQC). (
| Spine Fusion/ Refusion Clinical Episode-Based Payment Measure for program(s): HVBP (MUC ID: X0353) |
NQF Number (if applicable):
Programs under consideration: Hospital Value-Based Purchasing Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| Spine Fusion/ Refusion Clinical Episode-Based Payment Measure for program(s): IQR (MUC ID: X0353) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Conditional Support pending NQF review and endorsement
Preliminary analysis summary: This measure addresses the cost of care for a common inpatient surgical procedure. Utilization of spinal fusion is increasing rapidly and payments for this procedure vary significantly.
Does the measure address a critical program objective as defined by MAP? Yes. Yes, this measure addresses the cost of care for a common inpatient surgical procedure. Utilization of spinal fusion is increasing rapidly and payments for this procedure vary significantly.Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes, a large number of spinal fusions are performed annually and costs can vary significantly by provider. An episode-based approach could help drive improvement in both cost and quality.[i] Move towards more outcome measures rather than structure or process measures.N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources. N/A Engage patients and families as partners in their care.N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, this measure addresses cost. AHRQ estimates that spinal fusion costs in the U.S. are over $12 billion; a hospital cost for one procedure is roughly $27,000. A report from the GAO found that spinal fusions had the fastest increase in utilization of orthopedic implantable medical devices, increasing at a rate of 12.1% per year[ii]. The rates of this surgery in the U.S. are double those in most comparable first world countries and five times those of Great Britain and are expected to keep growing.[iii] An analysis of Medicare payments showed that payments for this procedure vary significantly.[iv] [i] http://content.healthaffairs.org/content/28/5/1406.full.pdf[ii] GAO. Lack of Price Transparency May Hamper Hospitals’ Ability To be Prudent Purchasers of Implantable Medical Devices. http://www.gao.gov/assets/590/587688.pdf[iii] http://www.modernhealthcare.com/article/20140322/MAGAZINE/303229985[iv] Acumen. Methodology for Developing the Six Hospital-based Episode Measures: Supplemental Documentation for the Fiscal Year 2015 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. Yes, this measure could help to address the variation in costs in a common hospital procedure.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: CMS is constructing episodes of
care because they allow meaningful comparisons between providers based on
resource use for certain clinical conditions or procedures, as noted in the
recent National Quality Forum draft report for the “Episode Grouper Evaluation
Criteria” project (see National Quality Forum (NQF) “Comment on the Proposed
Recommendations for Evaluating Episode Groupers.” (2014) Available at
http://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in
various peer-reviewed articles (see Peter S. Hussey, Melony E. Sorbero, Ateev
Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode-Based Performance
Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5
(2009):1406-1417. Available at
http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS
is constructing episodes of care in response to the mandate in Section 3003 of
the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of
Health and Human Services (HHS) develop an episode grouper to improve care
efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No.
111-148, § 3003, 124 Stat. 366 (2010)).
| SUB-2 Alcohol Use Brief Intervention Provided or Offered. SUB-2a Alcohol Use Brief Intervention Received. for program(s): IPFQRP (MUC ID: E1663) |
NQF Number (if applicable): 1663
Programs under consideration: Inpatient Psychiatric Facilities Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: This fully specified and tested endorsed measure fulfillsa gap in person-centered psychiatric care through the identification and management of general medical conditions
Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap in person-centered psychiatric care through the identification and management of general medical conditions.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No. This measure is not currently in use in a public or private program.
Does the measure promote alignment and parsimony? Yes. This measure contributes to the efficient use of measurement resources and supports alignment by filling a gap in person-centered psychiatric care through the identification and management of general medical conditions.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. This measure was endorsed in 2014 as part of Phase 2 of the Behavioral Health project
Rationale for measure provided by HHS: Excessive use of alcohol and
drugs 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
(The National Quality Forum, A consensus Report, 2007). In 1998 the economic
costs to society were 185 billion dollars for alcohol misuse and 143 billion
dollars for drug misuse (Harwood 2000). Health care spending was 19 billion
dollars for alcohol problems and 14 billion dollars was spent treating drug
problems. Nearly a quarter of a trillion dollars per year in lost productivity
is attributable to substance use. More than 537,000 die each year as a
consequence of alcohol, drug, and tobacco use, making use of these substances
the cause of one out of four deaths in the United States (Mokdad 2004). An
estimated 22.6 million adolescents and adults meet criteria for a substance use
disorder. In a multi-state study that screened 459,599 patients in general
hospital and medical settings, 23% of patients screened positive (Madras 2009).
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 (Fleming 2002). 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 (Gentilello 2005). Currently, less than one in twenty
patients with an addiction are referred for treatment (Gentilello 1999).
Hospitalization provides a prime opportunity to address the entire spectrum of
substance use problems within the health care system (Bernstein 2005).
| Thorax CT: Use of Contrast Material for program(s): MSSP (MUC ID: E0513) |
NQF Number (if applicable): 0513
Programs under consideration: Medicare Shared Savings Program
Preliminary analysis decision: Support
Preliminary analysis summary: This measure promotes alignment across other quality measurement reporting programs including the HOQR program and addresses gaps identified by MAP in imaging efficiency, utilization, and patient safety. In addition, this measure requires the use of administrative claims data that will not pose additional burden on providers reporting this measure. The Pulmonary and Critical Care Standing Committee noted in its 2013 review of this measure that this measure helps to address overuse and patient safety through the reduction of radiation exposure and potential reactions to contrast dye.
Does the measure address a critical program objective as defined by MAP? Yes. Yes. This measure addresses the critical program objectives to improve quality of health outcomes for the Medicare FFS subpopulations while lowering the rate of growth of health care spending thereby, combining the concept of resource use and quality. This measure also promotes alignment with other quality measurement reporting programs, and is a high value cost and resource use and appropriate use efficiency measure.· Critical Objectives· Improve the overall health for subpopulations within Medicare Fee-For-Service (FFS) beneficiaries;· Response: Yes this measure addresses an inefficiency of practice and a patient safety issue for Medicare FFS patients. · Improve quality and health outcomes while lowering the rate of growth of healthcare spending;· Response: This measure helps to reduce the risk of diagnostic imaging associated with unnecessary radiation exposure and adverse events related to contrast agents. The reduction of these unnecessary services can help to lower the rate of growth of unnecessary or harmful healthcare utilization. · Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), and measures that span across settings;· Response: This measure does not directly address care delivered across settings of care or providers. · Promote alignment across other quality measurement reporting programs (e.g end of life palliative care) ;· Response: This measure promotes alignment across other quality measurement reporting programs including the Hospital Outpatient Quality Reporting Program. · Include more high-value measures such as: o Patient-reported outcome measures in the areas of depression remission, functional status, and smoking; o Patient-reported outcome measures for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);o Measure of health risks with follow-up interventions; o Cost and resource use measures; ando Appropriate use measures.Response:Yes. The measure addresses a high value measure area identified by the MAP, specifically imaging efficiency and patient safety.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is currently in use in the OQR public program.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure promotes alignment across other quality measurement reporting programs including the OQR program and addresses gaps in imaging efficiency, utilization, and patient safety. In addition, this measure requires the use of administrative claims data that will not pose additional burden on providers reporting this measure. The Pulmonary and Critical Care Standing Committee noted in its 2013 review of this measure that this measure helps to address overuse and patient safety through the reduction of radiation exposure and potential reactions to contrast dye.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Addresses gaps in imaging
efficiency, utilization, and patient safety while supporting alignment with
other quality reporting programs.
| Timely Evaluation of High-Risk Individuals in the Emergency Department for program(s): IQR (MUC ID: X1234) |
NQF Number (if applicable):
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: MAP has previously stressed the importance of ED throughput measures as important markers of efficiency and safety which can dramatically impact patient experience. This measure in particular would address severely ill patients being admitted to the ED.
Does the measure address a critical program objective as defined by MAP? Yes. This is a high impact measure that reviews the time it took for a severely ill patient with the highest-level triage score to be evaluated by a provider, is also under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals. Critical Objectives: Choose high impact measures that will improve both quality and efficiency of care and are meaningful to consumers.Yes this measure could help promote a culture of safety. MAP has previously stressed the importance of ED throughput measures as important markers of efficiency and safety which can dramatically impact patient experience. This measure in particular would address severely ill patients being admitted to the EDMove towards more outcome measures rather than structure or process measures.N/AAlign reporting requirements with other clinical programs where appropriate to reduce the burden on providers and support efficient use of measurement resources.Under review for Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access HospitalsEngage patients and families as partners in their care. N/AExpand the program to include measures that allow rural and other small hospitals to participate.N/AIn the 2013-14 pre-rulemaking process, MAP recommended the rapid filling of the following fairly extensive gap list for this program: pediatrics, maternal/child health, cancer, behavioral health, affordability/cost, care transitions, patient education, palliative and end of life care, medication reconciliation, a culture of safety, pressure ulcer prevention, and adverse drug events. MAP suggested that HHS could look to existing measures in the PPS-Exempt Cancer Hospital Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and Hospice Quality Reporting Programs to begin to fill these gaps. Yes, while ED throughput is currently addressed in the IQR program, this measure could add valuable detail about the time severely ill patients must wait to be seen.
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No. Testing for this measure is still underway.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. This measure is not in use nor has it been reviewed as an e-Measure for endorsement.
Does the measure promote alignment and parsimony? Yes. This measure contributes to the efficient use of measurement resources by filling the MAP identified priority gap of creating a culture of safety. This measure is also under review for the Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals program.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: This is a new eCQM that
assesses a different aspect of ED provider care, and specifically assesses
provider timeliness to evaluation. The anticipated effect of implementing this
measure would be to reduce the time for high risk patients to be seen by a
physician in the emergency department and thereby reduce adverse events (i.e.,
morbidity and mortality). High-risk individuals are identified by assignment of
the highest or most urgent score from a valid triage system.
| Timely Evaluation of High-Risk Individuals in the Emergency Department for program(s): MUHCAH (MUC ID: X1234) |
NQF Number (if applicable):
Programs under consideration: Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs)
Preliminary analysis decision: Encourage continued development
Preliminary analysis summary: This efficiency measure affects a high impact population and captures important clinical data. It is also under review for the Hospital Inpatient Quality Reporting program. However, the measure is still in development as a e-Measure.
Does the measure address a critical program objective as defined by MAP? Yes. This is a high impact measure that reviews the time it took for a severely ill patient with the highest-level triage score to be evaluated by a provider, is also under review for Hospital Inpatient Quality Reporting. Critical Objectives:Preference should be given to NQF-endorsed quality measures. Not endorsedSelect measures that represent the future of measurement (facilitating information exchange between institutions and longitudinal tracking of care, such as measures that monitor incremental changes in a patient’s condition over time).This measure brings in important clinical data, specifically the triage score into the measure specifications. Identifying the efficiency of ED services for this subpopulation of patients is particularly important.Align the measure set with other hospital performance measurement programs.Under review for Hospital Inpatient Quality ReportingEnsure e-measures in the program are reliable and provide comparable results to paper-based measures. N/A
Measure development status: Early development
Is the measure fully tested for the program's setting and level of analysis? No.
Since no, could the measure be revised to use in the setting or at level of analysis under consideration? .
Is the measure currently in use? No. This measure is not in use nor has itbeen reviewed as an e-Measure for endorsement.
Does the measure promote alignment and parsimony? Yes. This efficiency measure affects a high impact population and captures important clinical data. It is also under review for the Hospital Inpatient Quality Reporting program.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is not in use nor has itbeen reviewed as an e-Measure for endorsement.
Rationale for measure provided by HHS: This is a new eCQM that
assesses a different aspect of ED provider care, and specifically assesses
provider timeliness to evaluation. The anticipated effect of implementing this
measure would be to reduce the time for high risk patients to be seen by a
physician in the emergency department and thereby reduce adverse events (i.e.,
morbidity and mortality). High-risk individuals are identified by assignment of
the highest or most urgent score from a valid triage system.
| Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) for program(s): IPFQRP (MUC ID: E0648) |
NQF Number (if applicable): 0648
Programs under consideration: Inpatient Psychiatric Facilities Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: This fully specified and tested NQF-endorsed process measure contributes to the efficient use of measurement resources and addresses a critical program objective and is highly impactful to patients by improving person-centered by facilitating care coordination and has the potential to reduce readmission. However this measure is duplicative of an existing measure, HBIPS-7 Post Discharge Continuing Care Plan Transmitted to Next Level Care Provider upon Discharge, which is developed and specified for psychiatric facilities. The two measures should be harmonized before being used in the IPFQR program.
Does the measure address a critical program objective as defined by MAP? Yes. This process measure addresses a critical program objective and is highly impactful to patients by improving person-centered by facilitating care coordination and has the potential to reduce readmission. While this measure is not currently in use in any public program, is under review in the Hospital Inpatient Quality Reporting Program.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. This measure is currently in use in private programs (ABIM MOC; Highmark; Buying Value core ambulatory measure) but not in public programs.
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. While this measure is duplicative of an existing paper record measure, HBIPS-7 Post Discharge Continuing Care Plan Transmitted to Next Level Care Provider upon Discharge, which is developed and specified for psychiatric facilities, this measure uses multiple data sources such as administrative claims, electronic clinical data, and paper medical records thus it contributes to the efficient use of measurement resources. It is recommended the measure be harmonized with HBIPS-7.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Initial endorsement in 2010, endorsement renewed in 2012
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: This measure is important to
decrease cost, address gaps in care, and enhance coordination of communication.
Cost • In 2006, there were over 39 million hospital discharges; of those, 13
percent of these patients are repeatedly hospitalized and use 60 percent of the
healthcare resources. • A 2007 report by the Medicare Payment Advisory
Commission estimated approximately 18 percent of admissions result in
readmissions within 30 days, costing CMS $15 billion. Gaps in Care: • Sabogal
and colleagues found that uncoordinated transitions between sites of care, even
within the same institution, and between caregivers increase hospital
readmissions, medical errors, duplication of services, and waste of resources.
• Moore and colleagues examined three types of discontinuity of care among older
patients transferred from the hospital: medication, test result follow-up, and
initiation of a recommended work-up. They found that nearly 50 percent of
hospitalized patients experienced at least one discontinuity and that patients
who did not have a recommended work-up initiated were six times more likely to
be re-hospitalized. • A prospective, cross-sectional study by Roy and
colleagues found that approximately 40 percent of patients have pending test
results at the time of discharge and that 10 percent of these require some ac
Emergency Department Visits • The 2008 National Health Statistics Report
determined that 2.3 million (2 percent) emergency department visits are from
patients who were discharged from the hospital within the previous 7 days. The
report also cited the following: • Ten percent of the 2.3 million emergency
department visits were for complications related to their recent
hospitalization, and • The uninsured are 3 times more likely to visit the
emergency department. Medication errors: • An estimated 60 percent of
medication errors occur during times of transition: upon admission, transfer, or
discharge of a patient. • During care transitions, patients receive medications
from different prescribers who rarely have access to patients’ comprehensive
medication list. • Forster and colleagues found that 19 percent of discharged
patients experienced an associated adverse event within three weeks of leaving
the hospital; 66 percent of these were adverse drug events. Coleman EA, Min S,
Chomiak A, Kramer AM. 2004. Post-hospital care transitions: patterns,
complications, and risk identification. Health Services Research 39:1449–1465.
Agency for Healthcare Research and Quality (ARHQ). 1999. Outcomes by Patient and
Hospital Characteristics for All Discharges. Available at:
http://www.ahrq.gov/HCUPnet.asp. Kramer A, Eilertsen T, Lin M, Hutt E. 2000.
Effects of nurse staffing on hospital transfer quality measures for new
admissions. Pp. 9.1–9.22. Inappropriateness of Minimum Nurse Staffing Ratios for
Nursing Homes. Health Care Financing Administration. Hutt E, Ecord M, Eilertsen
TB, et al. Precipitants of emergency room visits and acute hospitalization in
short-stay Medicare nursing home residents. J Am Geriatr Soc 2001; 50: 223-229.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program
to decrease rehospitalization. Ann Intern Med 2009; 150:178-187. Agency for
Healthcare Research and Quality (ARHQ). 2006. Outcomes by Patient and Hospital
Characteristics for All Discharges. Available at:
http://www.ahrq.gov/HCUPnet.asp. Medicare Payment Advisory Commission. A data
book: Healthcare spending and the Medicare program. June 2007. Available at:
http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf. Harris G.
Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006).
Available at:
http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=5088&partner=rssnyt&emc=rss.
Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions interventions:
Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2).
Moore C
| TOB-3 Tobacco Use Treatment Provided or Offered at Discharge AND TOB-3a Tobacco Use Treatment at Discharge for program(s): IPFQRP (MUC ID: E1656) |
NQF Number (if applicable): 1656
Programs under consideration: Inpatient Psychiatric Facilities Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: The endorsed measure which fills a gap in person-centered psychiatric care through the identification and management of general medical conditions is fully specified and tested at the facility level
Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap in person-centered psychiatric care through the identification and management of general medical conditions.
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? No. This measure is not currently in use in a public or private program.
Does the measure promote alignment and parsimony? Yes. This measure contributes to the efficient use of measurement resources and supports alignment by filling a gap in person-centered psychiatric care through the identification and management of general medical conditions.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. This measure was endorsed in 2014 as part of Phase 2 of the Behavioral Health project
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
435,000 deaths each year (CDC MMWR 2008; McGinnis 1993). Smoking is a known
cause of multiple cancers, heart disease, and stroke, complications of
pregnancy, chronic obstructive pulmonary disease, other respiratory problems,
poorer wound healing, and many other diseases (DHHS 2004). Tobacco use creates a
heavy cost to society as well as to individuals. Smoking-attributable health
care expenditures are estimated at 96 billion dollars per year in direct medical
expenses and 97 billion dollars in lost productivity (CDC 2007). There is strong
and consistent evidence that tobacco dependence interventions, if delivered in a
timely and effective manner, significantly reduce the smoker’s risk of suffering
from tobacco-related disease and improved outcomes for those already suffering
from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood 2003 and
1997; Rasmussen 2005; Hurley 2005; Critchley 2004; Ford 2007; Rigotti 2008).
Effective, evidence-based tobacco dependence interventions have been clearly
identified and include 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.
Studies indicate that the combination of counseling and medications is more
effective for tobacco cessation than either medication or counseling alone,
except in specific populations for which there is insufficient evidence of the
effectiveness of the FDA-approved cessation medications. These populations
include pregnant women, smokeless tobacco users, light smokers, and adolescents.
Tobacco dependence should be viewed as a chronic disease. The treatment of this
chronic disease is most effective when the initial interventions provided in the
hospital setting are continued upon discharge to other care settings.
| Transfusion Reaction (PSI 16) for program(s): IQR (MUC ID: E0349) |
NQF Number (if applicable): 0349
Programs under consideration: Inpatient Quality Reporting Program
Preliminary analysis decision: No longer under consideration by CMS
Preliminary analysis summary:
Does the measure address a critical program objective as defined by MAP? .
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis?
Is the measure currently in use?
Does the measure promote alignment and parsimony? .
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.
Rationale for measure provided by HHS: Transfusion reaction is a
health outcome measure. This measure captures illness or injury resulting from
administration of mismatched blood or blood products, based on ABO or Rh
antigens. These events are considered to be almost entirely preventable. For
example, the 2011 Update of the NQF Serious Reportable Events in Healthcare
includes this specification of “Patient death or serious injury associated with
unsafe administration of blood products”: “Unsafe administration includes, but
is not limited to hemolytic reactions and administering a) blood or blood
products to the wrong patient; b) the wrong type; or c) blood or blood products
that have been improperly stored or handled.” Similarly, “Hemolytic transfusion
reaction involving administration of blood or blood products having major blood
group incompatibilities” is classified as a sentinel event by The Joint
Commission. Preoperative evaluation of a patient for blood transfusion includes
(1) reviewing previous medical records, (2) conducting a patient or family
interview, and (3) reviewing laboratory test results. American Society of
Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant
Therapies. Practice guidelines for perioperative blood transfusion and adjuvant
therapies: an updated report by the American Society of Anesthesiologists Task
Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology.
2006 Jul;105(1):198-208. According to one recent review (Janatpour KA, Kalmin
ND, Jensen HM, Holland PV. Clinical outcomes of ABO-incompatible RBC
transfusions. Am J Clin Pathol 2008; 129(2):276-81), “the most frequent error
leading to transfusion of ABO-incompatible blood is failure of the final patient
identification check at the bedside, leading to transfusion of properly labeled
blood to a recipient other than the one intended. In a recent report from
Ireland´s hemovigilance system, more than half of all adverse reactions to blood
transfusion were caused by the patient being given the wrong blood component.
The relative distribution of errors in our cases and survey results are similar
to those in other reports, with failures in pretransfusion verification of
patient identification comprising a majority of all errors, followed by
laboratory errors, and errors in sample collection and labeling… With an
increased awareness of the root causes of transfusion errors, hospitals have
taken steps to address them, such as requiring 2 pre-transfusion samples to
confirm a patient´s initial ABO blood type result (independent of the American
Association of Blood Banks standard requiring 2 determinations of the
recipient´s ABO type if using computer crossmatching). In theory, requiring a
second sample to confirm the ABO blood type could significantly reduce
ABO-incompatible transfusion because the vast majority of errors are due to
sample collection and labeling and bedside errors. A reduction in the use of
stationary refrigerators in the operating room is reported to have reduced some
transfusion errors… Various devices have also been introduced to minimize errors
in sample collection and transfusion to the intended recipient and have
prevented some errors. These are summarized in a recent review. However, it is
difficult to know whether actual use of these devices is widespread and their
effectiveness in preventing ABO-incompatible transfusions…. Quality improvement
dictates that analysis of adverse sentinel events such as ABO-incompatible
transfusions be performed. When such an event has been identified, corrective
measures should be instituted to prevent recurrences.
| Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) for program(s): IPFQRP (MUC ID: E0647) |
NQF Number (if applicable): 0647
Programs under consideration: Inpatient Psychiatric Facilities Quality Reporting Program
Preliminary analysis decision: Support
Preliminary analysis summary: The fully specified and tested endorsed measure is impactful and fills a gap in care coordination by ensuring that patients receive important transition information.
Does the measure address a critical program objective as defined by MAP? . This process measure addresses a critical program objective and is highly impactful to patients by improving person-centered psychiatric care by facilitating care coordination and has the potential to reduce readmission. While this measure is not currently in use in any public program, is under review in the Hospital Inpatient Quality Reporting Program. Critical ObjectivesEnsure measures in the program are meaningful to patients. YesAlign the reporting requirements in CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to allow consumers to compare across facility types and to reduce burden for facilities that participate in these programs. Not in use in any public programs; under review in Hospital Inpatient Quality Reporting Program Improve person-centered psychiatric care, such as assessing patient and family/caregiver experience and engagement and establishing relationships with community resources, are priority measure gap areas.YesMeasure gaps in the IPFQR program include step down care, behavioral health assessments and care in the ED, readmissions, identification and management of general medical conditions, partial hospitalization or day programs, and a psychiatric care module for CAHPS. Readmissions
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes.
Is the measure currently in use? Yes. The measure is not in use in public programs, however, is in use in at least two private programs (ABIM MOC; Highmark).
Does a review of its performance history raise any concerns? .
Does the measure promote alignment and parsimony? Yes. This measure fills a gap in care coordination by ensuring that patients receive important transition records with five elements. These elements ensure that a patient or their caregiver has information related to their Inpatient Care, Post-Discharge/ Patient Self-Management Plan, Advance Care Plan, and Contact Information/Plan for Follow-up Care.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. This measure is NQF-endorsed. Initial endorsement in 2010, endorsement renewed in 2012
Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
Rationale for measure provided by HHS: This measure is important to
decrease cost, address gaps in care, and enhance coordination of communication.
Cost • In 2006, there were over 39 million hospital discharges; of those, 13
percent of these patients are repeatedly hospitalized and use 60 percent of the
healthcare resources. • A 2007 report by the Medicare Payment Advisory
Commission estimated approximately 18 percent of admissions result in
readmissions within 30 days, costing CMS $15 billion. Gaps in Care: • Sabogal
and colleagues found that uncoordinated transitions between sites of care, even
within the same institution, and between caregivers increase hospital
readmissions, medical errors, duplication of services, and waste of resources.
• Moore and colleagues examined three types of discontinuity of care among older
patients transferred from the hospital: medication, test result follow-up, and
initiation of a recommended work-up. They found that nearly 50 percent of
hospitalized patients experienced at least one discontinuity and that patients
who did not have a recommended work-up initiated were six times more likely to
be re-hospitalized. • A prospective, cross-sectional study by Roy and
colleagues found that approximately 40 percent of patients have pending test
results at the time of discharge and that 10 percent of these require some ac
Emergency Department Visits • The 2008 National Health Statistics Report
determined that 2.3 million (2 percent) emergency department visits are from
patients who were discharged from the hospital within the previous 7 days. The
report also cited the following: • Ten percent of the 2.3 million emergency
department visits were for complications related to their recent
hospitalization, and • The uninsured are 3 times more likely to visit the
emergency department. Medication errors: • An estimated 60 percent of
medication errors occur during times of transition: upon admission, transfer, or
discharge of a patient. • During care transitions, patients receive medications
from different prescribers who rarely have access to patients’ comprehensive
medication list. • Forster and colleagues found that 19 percent of discharged
patients experienced an associated adverse event within three weeks of leaving
the hospital; 66 percent of these were adverse drug events. Coleman EA, Min S,
Chomiak A, Kramer AM. 2004. Post-hospital care transitions: patterns,
complications, and risk identification. Health Services Research 39:1449–1465.
Agency for Healthcare Research and Quality (ARHQ). 1999. Outcomes by Patient and
Hospital Characteristics for All Discharges. Available at:
http://www.ahrq.gov/HCUPnet.asp. Kramer A, Eilertsen T, Lin M, Hutt E. 2000.
Effects of nurse staffing on hospital transfer quality measures for new
admissions. Pp. 9.1–9.22. Inappropriateness of Minimum Nurse Staffing Ratios for
Nursing Homes. Health Care Financing Administration. Hutt E, Ecord M, Eilertsen
TB, et al. Precipitants of emergency room visits and acute hospitalization in
short-stay Medicare nursing home residents. J Am Geriatr Soc 2001; 50: 223-229.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program
to decrease rehospitalization. Ann Intern Med 2009; 150:178-187. Agency for
Healthcare Research and Quality (ARHQ). 2006. Outcomes by Patient and Hospital
Characteristics for All Discharges. Available at:
http://www.ahrq.gov/HCUPnet.asp. Medicare Payment Advisory Commission. A data
book: Healthcare spending and the Medicare program. June 2007. Available at:
http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf. Harris G.
Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006).
Available at:
http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=5088&partner=rssnyt&emc=rss.
Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions interventions:
Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2).
Moore C
| Unplanned Anterior Vitrectomy for program(s): ASCQRP (MUC ID: X3720) |
NQF Number (if applicable): N/A
Programs under consideration: Ambulatory Surgical Centers Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the completion of reliability testing and NQF endorsement. This high impact outcome measure fulfills a MAP identified gap but reliability testing has not been completed and the measure is not NQF endorsed.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is highly impactful and meaningful to patients. According to the National Eye Institute report in 2002[1], more than half of US residents over 65 years have a cataract. Cataracts are a leading cause of blindness, with more then 1.5 million cataract surgeries performed annually to improve the vision of those with cataracts. An Anterior Vitrectomy, the repair of a rupture in a mainly liquid portion of the eye, is generally an unplanned complication of a cataract surgery. This is an outcome measure that fills the workgroup identified priority gap of procedure complications.Critical Objectives:Include measures that have high impact and are meaningful to patients.This measure assesses how often a certain complication of cataract surgery occurs among all patients undergoing cataract surgery at a given facility. Given that reliability testing is still ongoing, performance data is not yet available. This measure is highly impactful and meaningful to patients. According to the National Eye Institute report in 2002[2], more than half of US residents over 65 years have a cataract. Cataracts are a leading cause of blindness, with more then 1.5 million cataract surgeries performed annually to improve the vision of those with cataracts. An Anterior Vitrectomy, the repair of a rupture in a mainly liquid portion of the eye, is generally an unplanned complication of a cataract surgery.Align measures with CMS’ various quality reporting programs, particularly the Hospital Outpatient Quality Reporting program, to facilitate comparisons across care settings, and to reduce burden for facilities that participate in these programsThis measure is not in or under review for any programsPriority measure gap areas for the ASCQR program include surgical care quality, infection rates, follow-up after procedures, complications including anesthesia related complications, cost, and patient and family engagement measures including an ASC-specific CAHPS module and patient-reported outcome measures This is related to complications during cataract surgery. [1] http://www.surgeryencyclopedia.com/Pa-St/Phacoemulsification-for-Cataracts.html[2] http://www.surgeryencyclopedia.com/Pa-St/Phacoemulsification-for-Cataracts.html
Measure development status: Field testing
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure has been tested in the ambulatory setting. All testing except reliability testing has been completed. Reliability testing started July 2014.
Is the measure currently in use? No. This measure is not currently in use in any public or private programs.
Does the measure promote alignment and parsimony? Yes. As an outcome measure, the measure contributes to an efficient use of measurement and supports alignment by filling a gap related to cataract surgery complications.
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has not been submitted for NQF-endorsement for the program’s setting and level of analysis.
Rationale for measure provided by HHS: Cataract surgery is a commonly
performed operation and should be associated with low intra-operative morbidity.
| Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache for program(s): OQR (MUC ID: X607) |
NQF Number (if applicable):
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: UPDATE TO FINALIZED MEASURE)Conditional support pending NQF endorsement. This measure would help to improve efficiency and reduce unnecessary ulitization of imaging in the ED for patients presenting with an atraumatic headache where the clinicial value of imaging appears limited.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is impactful since the 2012 report on the National Quality Strategy and the Centers for Medicare & Medicaid Services (CMS) both stressed the development of efficiency measures as high priority areas and the workgroup identified a need for emergency department (ED) measures.Critical Objectives:Include measures that have high impact and are meaningful to patients.Response: Development of efficiency measures is one of the primary objectives highlighted by both the 2012 report on the National Quality Strategy and the Centers for Medicare & Medicaid Services (CMS). However, there are potential for unintended consequences with the use of the measure. For example, there were concerns that older patients with headache could have other clinical reasons for imaging, such as use of oral anticoagulants that would not be captured in this claims-based measure. Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: NoSpecific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module.Response: Addresses efficiency particularly for patients in the ED
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? No.
Does the measure promote alignment and parsimony? Yes. While there are other measures that address Computed Tomography (CT) scanning, there are no other efficiency measures that address CT scanning in the Emergency Department for Atraumatic Headache
Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.
Rationale for measure provided by HHS: Development of efficiency
measures is one of the primary objectives highlighted by both the 2012 report on
the National Quality Strategy and the Centers for Medicare & Medicaid
Services (CMS). This measure's concept is similar to one which was identified
within the 2011 release of the Choosing Wisely campaign recommendations as an
area of concern. Moreover, there is evidence that diagnostic imaging for
headaches is overused, with only 2% of patient scans yielding pathology.
Unnecessary imaging is costly and needlessly exposes patients to radiation.
| Vital Signs for program(s): OQR (MUC ID: E0292) |
NQF Number (if applicable): 0292
Programs under consideration: Hospital Outpatient Quality Reporting Program
Preliminary analysis decision: Conditional support
Preliminary analysis summary: Conditional support pending the development of the single composite measure. This measure would help to address a previously identified gap around improving care coordination and would help ensure vital information is transfered between sites of care.
Does the measure address a critical program objective as defined by MAP? Yes. This measure is a component of Emergency Department Transfer Communication Measure set, which consists of seven components that focus on communication between facilities around the transfer of patients. The measure set assists in filling the workgroup identified priority gap of enhancing care coordination efforts. This specific measure analyzes if the medical record documentation indicated that the entire vital signs record, which includes information on the patient’s pulse, respiratory rate, blood pressure, oxygen saturation, temperature and glasgow score (where appropriate), was communicated to the receiving facility within 60 minutes of departure.Critical Objectives:Align the OQR with ambulatory care measures in programs such as Physician Quality Reporting System and Physician Compare. Response: No Specific gap areas for the OQR program measure set include measures of emergency department (ED) overcrowding, wait times, and disparities in care—specifically, disproportionate use of EDs by vulnerable populations. Other gaps include measures of cost, patient-reported outcomes, patient and family engagement, follow-up after procedures, fostering important ties to community resources to enhance care coordination efforts, and an outpatient CAHPS module. Response: Yes- enhance care coordination efforts
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. This measure was tested at the facility level.
Is the measure currently in use? Yes. This measure is not currently being used in any public programs but it is in use in at least one private program (Blue Cross Blue Shield of Massachusetts Alternative Quality Contract).
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. This measure is used in at least one private program and is part of the MAP Care Coordination Family of Measures.
Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was initially endorsed in 2007; endorsement was renewed in September 2014 during the Care Coordination project. The measure developer has agreed to combine the seven elements from measures 0291-0297 into a single composite measure based on the recommendations by the NQF Care Coordination Standing Committee.
Rationale for measure provided by HHS: Patients who are transferred
from an Emergency Department to another acute facility are excluded from the
calculation of most national quality measures, such as the Hospital Compare
measures. In addition, limited attention has been paid to the development and
implementation of quality measures specifically focused on patient transfers
between Emergency Departments and other facilities. This type of measure is
important for all healthcare facilities, but is especially important for small
rural hospitals, which transfer a higher proportion of Emergency Department
patients to other hospitals than do larger urban facilities (Newgard CD 2006,
Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).
Communication problems are a major contributing factor to adverse events in
hospitals, accounting for 65% of sentinel events tracked by the Joint Commission
(JCAHO 2007). In addition, research indicates that deficits exist in the
transfer of patient information between hospitals and primary care physicians in
the community (Kripalani S 2007), and between hospitals and long term facilities
(Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal
#2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement
2E for this goal requires all accredited hospitals to implement a standardized
approach to hand-off communications, including nursing and physician hand-offs
from the emergency department to inpatient units, other hospitals, and other
types of health care facilities. The process must include a method of
communicating up-to-date information regarding the patient’s care, treatment and
services, condition and any recent or anticipated changes (JCAHO-2 2007). 1.
Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in
Hospitalized Patients. Results of the Harvard Medical Practice Study II. New
England Journal of Medicine 324:377-384, 1991. 2. Thomas, E., Studdert, D.,
Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in
Utah and Colorado. Medical Care 38:261-271, 2000. 3. Schenkel, S. Promoting
Patient Safety and Preventing Medical Error in Emergency Departments. Academic
Emergency Medicine 7:1204-1222, 2000. 4. Welch, S., Augustine, J., Camago, C.
and Reese, C. Emergency Department Performance Measures and Benchmarking Summit.
Academic Emergency Medicine, 13(10):1074-1080, 2006. 5. Newgard CD, McConnell
KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care
hospital emergency departments. . Academic Emergency Medicine 13:746-754, 2006.
6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and
interhospital transfers as potential indicators of rural hospital quality.
Journal of Rural Health. 20:394-400, 2004. 7. Ellerbeck EF, Bhimaraj A, Perpich
D. Organization of care for acute myocardial infarction in rural and urban
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| MUC ID: X3629 30 Day Unplanned Readmissions for Cancer Patients |
NQF Number (if applicable):
Description: Number of hospital-specific 30-day unscheduled and potentially avoidable readmissions following hospitalization among diagnosed malignant cancer patients
Numerator statement: Total number of unscheduled readmissions within 30 days of index admission
Denominator statement: Total PPS-Exempt Cancer Center admissions within the reporting year for patients [aged 18+] discharged alive from the facility with an active malignant cancer diagnosis
Exclusions: Numerator Exclusions: Medical exclusions (1P) only are permitted for this measure, for example, patients who develop metastatic disease progression and/or planned therapy (for example chemotherapy) Denominator Exclusions: 1. Patients readmitted to another acute care center Rationale: Full data for admissions outside of index facility may be unavailable. This also includes admissions for primary diagnoses of psychiatric disease (cared for in separate psychiatric or rehabilitation centers and do not compare to acute care facilities). 2. Patients that left Against Medical Advice in the index admission Rationale: Hospital had limited opportunity to implement high quality care. 3. Patients that were transferred to Another Acute Care facility in the index admission Rationale: This does not capture the target population of patients who may benefit from the specifications of the measure. 4. Admissions for patients without 30 days of post-discharge data Rationale: This is necessary in order to identify readmissions in the dataset. 5. Admissions for patients without a complete enrollment history for the 12 months prior to admission Rationale: This is necessary to capture historical data for (pending) risk adjustment.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Clinical Data
Measure type: Outcome
Steward: Alliance of Dedicated Cancer Centers
Endorsement Status: Not Endorsed
| MUC ID: E0291 Administrative Communication |
NQF Number (if applicable): 0291
Description: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that administrative information was communicated to the receiving facility within prior to departure
Numerator statement: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that administrative information was communicated to the receiving facility prior to departure • Nurse communication with receiving hospitals • Practitioner communication with receiving practitioner or transfer coordinator[For reference, numerator for endorsed measure in QPS: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that administrative and clinical information was communicated to the receiving facility IN AN APPROPRIATE TIME FRAME• EDTC-SUB 1 Administrative communication- Nurse to nurse communication- Physician to physician communication• EDTC-SUB 2 Patient information- Name- Address- Age- Gender- Significant others contact information- Insurance• EDTC-SUB 3 Vital signs- Pulse- Respiratory rate- Blood pressure- Oxygen saturation- Temperature- Glasgow score or other neuro assessment for trauma, cognitively altered or neuro patients only• EDTC-SUB 4 Medication information- Medications administered in ED- Allergies- Home medications• EDTC-SUB 5 Physician or practitioner generated information- History and physical- Reason for transfer and/or plan of care• EDTC-SUB 6 Nurse generated information- Assessments/interventions/response- Sensory Status (formerly Impairments)- Catheters- Immobilizations- Respiratory support- Oral limitations• EDTC-SUB 7 Procedures and tests- Tests and procedures done- Tests and procedure results sent]
Denominator statement: All emergency department patients who are transferred to another healthcare facility
Exclusions: All emergency department patients not discharged to another healthcare facility.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record, Prescription Drug Event Data Elements
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: E0326 Advance Care Plan |
NQF Number (if applicable): 0326
Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. [Description differs from posted MUC list based on NQF staff analysis]
Numerator statement: Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. [Numerator differs from posted MUC list based on NQF staff analysis]
Denominator statement: All patients aged 65 years and older.
Exclusions: None
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Administrative Claims, EHR
Measure type: Process
Steward: National Committee for Quality Assurance
Endorsement Status: Endorsed
| MUC ID: X3323 Adverse Drug Events: - Inappropriate Renal Dosing of Anticoagulants |
NQF Number (if applicable):
Description: Percentage of patient-drug days with administration of anticoagulants requiring renal dosing with at least one error in renal dosing
Numerator statement: The total number of patient-drug days with at least one renal dosing error.
Denominator statement: The total number of patient-drug days with administration of anticoagulants requiring renal dosing.
Exclusions: Admissions for individuals less than 18 years old. 2. Admissions that are for observation only. 3. Admissions with length of stay greater than or equal to 120 days. 4. Admissions with length of stay less than 24 hours. 5. Drugs administered in the OR. 6. Admissions on dialysis of any kind. 7. Antibiotics given less than 2 hours prior to surgery and up to 24 hours post-surgery are ignored. Ignore the first dose of antibiotic more than 2 hours before surgery and the first dose more than 24 hours after surgery. 8. First 96 hours of drugs for patients with labor & delivery codes.
HHS NQS Priority: Making Care Safer
HHS Data Source: EHR
Measure type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0515 Ambulatory surgery patients with appropriate method of hair removal |
NQF Number (if applicable): 0515
Description: Percentage of ASC admissions with appropriate surgical site hair removal.
Numerator statement: ASC admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream from all other surgical sites
Denominator statement: All ASC admissions with surgical site hair removal
Exclusions: ASC admissions who perform their own hair removal
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record
Measure type: Process
Steward: ASC Quality Collaboration
Endorsement Status: Endorsed
| MUC ID: X2698 AMI episode of care (inpatient hospitalization + 30 days post-discharge) |
NQF Number (if applicable): N/A
Description: Hospital-specific, risk-standardized, 30-day episode of care payment for AMI. The measure includes all payments across care settings for the 30-days following an inpatient admission for AMI. The payments are either "stripped” or “standardized" to remove the effect of policy adjustments. The measure uses hierarchical modelling to estimate hospital-level risk-standardized total payments for the 30-day window from admission.
Numerator statement: The outcome for this measure is Medicare payments for an AMI episode of care. The payment timeframe is defined as admission for an index hospitalization through 30 days post-admission. We include payments for inpatient settings and up to 6 other post-discharge settings (Skilled Nursing Facility, Outpatient, Home Health Agency, Hospice, Carrier, and Durable Medical Equipment).
Denominator statement: The target population for this measure includes episodes of care (as defined above) for patients who are 65 years of age or older with a principal discharge diagnosis of AMI (as defined by ICD-9 codes 410.xx, excluding 410.x2) during a qualifying index hospitalization.
Exclusions: Lack of continuous enrollment in Medicare FFS Parts A and B in the 12 months prior to index hospital stay. 2) Lack of continuous enrollment in Medicare FFS Parts A and B in the month following the index hospital stay (if alive). 3) Patients discharged alive on the day of admission who did not get transferred. 4) Transfers into the hospital (excluded from eligibility as an index admission), or transfers to federal hospitals. 5) Patients who are discharged against medical advice (AMA). 6) Occurred in Maryland hospitals and U.S. territories. 7)Episodes for Patients with 0 Payment
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Cost/ Resource Use
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3811 Anesthesiology Smoking Abstinence |
NQF Number (if applicable):
Description: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.
Numerator statement: Patients as defined in the Denominator who are identified as current cigarette smokers and who abstained from smoking prior to anesthesia on the day of surgery or procedure. Abstinence may be defined by either patient self-report or an exhaled carbon monoxide level of < 10 ppm. Numerator Includes: Patients 18 and older AND Are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure AND Are identified as current cigarette smokers AND Abstained from smoking prior to anesthesia on the day of surgery or procedure
Denominator statement: All patients aged 18 years and older who are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure. Denominator Includes: Patients 18 and older AND Are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include routine screening for smoking status with instruction to abstain from smoking on the day of surgery or procedure AND Are identified as current cigarette smokers
Exclusions: Non-elective emergent surgery
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Intermediate Outcome
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: E0225 At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer |
NQF Number (if applicable): 0225
Description: Percentage of patients >18yrs of age, who have primary colon tumors (epithelial malignancies only), experiencing their first diagnosis, at AJCC stage I, II or III who have at least 12 regional lymph nodes removed and pathologically examined for resected colon cancer. 1b.1. Developer Rationale: Improved survival for patients
Numerator statement: Greater than or equal to 12 regional lymph nodes pathologically examined.
Denominator statement: Regional Lymph Nodes Positive[For reference, denominator of endorsed measure in QPS: Include, if all of the following characteristics are identified:Age >=18 at time of diagnosisKnown or assumed to be first or only cancer diagnosisPrimary tumors of the colonEpithelial malignancy onlyAJCC Stage I, II, or IIISurgical resection performed at the reporting facility]
Exclusions: Exclude, if any of the following characteristics are identified: Age <18; not a first or only cancer diagnosis; non-epithelial and non-invasive tumors; metastatic disease (AJCC Stage IV); not treated surgically at the reporting facility
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record, Registry
Measure type: Process
Steward: American College of Surgeons
Endorsement Status: Endorsed
| MUC ID: E0642 Cardiac Rehabilitation Patient Referral From an Inpatient Setting |
NQF Number (if applicable): 0642
Description: Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.
Numerator statement: Number of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient Cardiac Rehabilitation/Secondary Prevention (CR/SP) program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made.[For reference, additional numerator text included for NQF endorsed measure on QPS: (Note: The program may include a traditional CR/SP program based on face-to-face interactions and training sessions or may include other options such as home-based approaches. If alternative CR/SP approaches are used, they should be designed to meet appropriate safety standards and deliver effective, evidence-based services.)]
Denominator statement: Number of hospitalized patients in the reporting period hospitalized with a qualifying cardiovascular disease event/diagnosis who do not meet any of the criteria listed in the denominator exclusion section below.
Exclusions: Exceptions criteria require documentation of one or more of the following factors that may prohibit cardiac rehabilitation participation: Patient factors (e.g., patient resides in a long-term nursing care facility). Medical factors (e.g., patient deemed by provider to have a medically unstable, life-threatening condition). Health care system factors (e.g., no cardiac rehabilitation/secondary prevention (CR/SP) program available within 60 min of travel time from the patient’s home). The only exclusion criterion for this measure is noted below: Patients who expired before discharge.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: EHR, Paper Medical Record, Registry
Measure type: Process
Steward: American College of Cardiology
Endorsement Status: Endorsed
| MUC ID: X0354 Cellulitis Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Cellulitis Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Cellulitis episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a cellulitis hospital admission. The Cellulitis Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Cellulitis Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the cellulitis treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Cellulitis Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to cellulitis across a provider’s eligible cellulitis episodes during the period of performance. A cellulitis episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s cellulitis episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Adminstrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0351 Death among surgical inpatients with serious, treatable complications (PSI 4) |
NQF Number (if applicable): 0351
Description: Percentage of cases having developed specified complications of care with an in-hospital death.
Numerator statement: All discharges with a disposition of “deceased” (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator.
Denominator statement: All surgical discharges age 18 years and older or MDC 14 (pregnancy, childbirth, and puerperium) defined by specific DRGs or MS-DRGs and an ICD-9-CM code for an operating room procedure, principal procedure within 2 days of admission OR admission type of elective (ATYPE=3) with potential complications of care listed in Death among Surgical definition (e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer).
Exclusions: Exclude cases: • age 90 years and older • transferred to an acute care facility (DISP = 2) • missing discharge disposition (DISP=missing), gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1 =missing)
HHS NQS Priority: Making Care Safer
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Agency for Healthcare Research & Quality
Endorsement Status: Endorsed
| MUC ID: X3747 Door to puncture time for endovascular stroke treatment |
NQF Number (if applicable):
Description: Door to puncture time less than 2 hours for patients undergoing endovascular stroke treatment
Numerator statement: Patients with acute ischemic stroke undergoing endovascular stroke treatment who have a door to puncture time of less than 2 hours
Denominator statement: All patients with acute ischemic stroke undergoing endovascular stroke treatment
Exclusions: Patients who are transferred from one institution to another with a known diagnosis of acute ischemic stroke for endovascular stroke treatment; In-patients with newly diagnosed acute ischemic stroke considered for endovascular stroke treatment
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record, Registry
Measure type: Intermediate Outcome
Steward: Society of Interventional Radiology
Endorsement Status: Not Endorsed
| MUC ID: E1822 External Beam Radiotherapy for Bone Metastases |
NQF Number (if applicable): 1822
Description: This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.
Numerator statement: All patients, regardless of age, with painful bone metastases, and no previous radiation to the same anatomic site who receive EBRT with any of the following recommended fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns, 8Gy/1fxn.
Denominator statement: All patients with painful bone metastases and no previous radiation to the same anatomic site who receive EBRT
Exclusions: The medical reasons for denominator exclusions are: 1) Previous radiation treatment to the same anatomic site; 2) Patients with femoral axis cortical involvement greater than 3 cm in length; 3) Patients who have undergone a surgical stabilization procedure; and 4) Patients with spinal cord compression, cauda equina compression or radicular pain
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: EHR, Paper Medical Record
Measure type: Process
Steward: American Society for Radiation Oncology
Endorsement Status: Endorsed
| MUC ID: E0202 Falls with injury |
NQF Number (if applicable): 0202
Description: All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days. (Total number of injury falls / Patient days) X 1000 Measure focus is safety. Target population is adult acute care inpatient and adult rehabilitation patients.
Numerator statement: Total number of patient falls of injury level minor or greater (whether or not assisted by a staff member) by eligible hospital unit during the calendar month X 1000.[For reference, additional text about this NQF endorsed measure from QPS:Included Populations: • Falls with Fall Injury Level of “minor” or greater, including assisted and repeat falls with an Injury level of minor or greater• Patient injury falls occurring while on an eligible reporting unit Target population is adult acute care inpatient and adult rehabilitation patients. Eligible unit types include adult critical care, step-down, medical, surgical, medical-surgical combined, critical access, adult rehabilitation in-patient.]
Denominator statement: Patient days by Type of Unit during the calendar month.[For reference, additional text about this NQF endorsed measure from QPS:Included Populations: •Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on eligible inpatient units for all or part of a day on the following unit types:•Adult critical care, step-down, medical, surgical, medical-surgical combined, critical access and adult rehabilitation inpatient units.•Patients of any age on an eligible reporting unit are included in the patient day count.]
Exclusions: Other unit types (e.g., pediatric, psychiatric, obstetrical, etc.)
HHS NQS Priority: Making Care Safer
HHS Data Source: EHR, Paper Medical Record
Measure type: Outcome
Steward: American Nurses Association
Endorsement Status: Endorsed
| MUC ID: X0355 Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Gastrointestinal Hemorrhage episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a gastrointestinal hemorrhage hospital admission. The Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the gastrointestinal hemorrhage treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to gastrointestinal hemorrhage across a provider’s eligible gastrointestinal hemorrhage episodes during the period of performance. A gastrointestinal hemorrhage episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s gastrointestinal hemorrhage episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Adminstrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E1898 Health literacy measure derived from the health literacy domain of the C-CAT |
NQF Number (if applicable): 1898
Description: 100 measure of health literacy related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit
Numerator statement: Health literacy component of patient-centered communication: an organization should consider the health literacy level of its current and potential populations and use this information to develop a strategy for the clear communication of medical information verbally, in writing and using other media. Measure is scored based on 15 items from the patient survey of the C-CAT and 13 items from the staff survey of the C-CAT. Minimum of 100 patient responses and 50 staff responses.
Denominator statement: There are two components to the target population: staff (clinical and nonclinical) and patients. Sites using this measure must obtain at least 50 staff responses and at least 100 patient responses.
Exclusions: Staff respondents who do not have direct contact with patients are excluded from questions that specifically address patient contact.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Outcome
Steward: American Medical Association
Endorsement Status: Endorsed
| MUC ID: X0356 Hip Replacement/ Revision Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Hip Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Hip Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a hip replacement/revision. The Hip Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Hip Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the hip replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Hip Replacement/Revision Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the hip replacement/revision across a provider’s eligible hip replacement/revision episodes during the period of performance. A hip replacement/revision episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s hip replacement/revision episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Adminstrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E1641 Hospice and Palliative Care – Treatment Preferences |
NQF Number (if applicable): 1641
Description: Percentage of patients with chart documentation of preferences for life sustaining treatments.
Numerator statement: Patients whose medical record includes documentation of life sustaining preferences
Denominator statement: Seriously ill patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting.
Exclusions: Patients with length of stay < 1 day in palliative care or < 7 days in hospice
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: EHR, Other (please list in GTL comment field)
Measure type: Process
Steward: University of North Carolina- Chapel Hill
Endorsement Status: Endorsed
| MUC ID: E1893 Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization |
NQF Number (if applicable): 1893
Description: The measure estimates a hospital-level risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients 40 and older discharged from the hospital with either a principal diagnosis of COPD or a principal diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD. CMS will annually report the measure for patients who are 65 years or older, enrolled in fee-for-service (FFS) Medicare, and hospitalized in non-federal hospitals.
Numerator statement: The outcome for this measure is 30-day all-cause mortality. We define mortality as death from any cause within 30 days from the date of admission for patients 40 and older discharged from the hospital with either a principal diagnosis of COPD or a principal diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD.
Denominator statement: This claims-based measure can be used in either of two patient cohorts: (1) patients aged 65 years or older or (2) patients aged 40 years or older. The cohort includes admissions for patients discharged from the hospital with either a principal diagnosis of COPD OR a principal diagnosis of respiratory failure WITH a secondary diagnosis of acute exacerbation of COPD and with a complete claims history for the 12 months prior to admission.
Exclusions: The measure excludes index admissions for patients: 1. Discharged alive on the day of admission or the following day who were not transferred; 2. With inconsistent or unknown vital status or other unreliable demographic data; 3. Enrolled in the Medicare hospice program any time in the 12 months prior to the index admission, including the first day of the index admission; and 4. Who were discharged against medical advice (AMA).[For reference, additional exclusion text for endorsed measure in QPS:After the above exclusions (#1-4) are applied, the measure randomly selects one index admission per patient per year for inclusion in the cohort. Each episode of care must be mutually independent with the same probability of the outcome. The probability of death increases with each subsequent admission and therefore the episodes of care are not mutually independent. For the three year combined data, when index admissions occur during the transition between measure reporting periods (June and July of each year) and both are randomly selected for inclusion in the measure, the measure only includes the June admission. The July admissions are excluded from the measure to avoid assigning a single death to two admissions.]
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: E0468 Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization |
NQF Number (if applicable): 0468
Description: The measure estimates a hospital 30-day risk-standardized mortality rate (RSMR), defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of pneumonia. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.
Numerator statement: The outcome for this measure is 30-day all-cause mortality. We define mortality as death from any cause within 30 days of the index admission date for patients 18 and older discharged from the hospital with a principal diagnosis of pneumonia.[For reference, additional text on numerator included for endorsed measure on QPS: The numerator of the risk-adjusted ratio is the predicted number of deaths within 30 days given the hospital’s performance with its observed case mix. The term “predicted” describes the numerator result, which is calculated using the hospital-specific intercept term. (See details below in the 2a1.13 Statistical risk model and variables.)]
Denominator statement: The denominator includes patients aged 18 and over admitted to an acute care hospital for pneumonia and with a complete claims history for the 12 months prior to admission. The measure is currently publicly reported by CMS for those 65 years and older who are either Medicare FFS beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. In 2014, we propose updating our current definition of pneumonia to include patients with a principal discharge diagnosis of aspiration pneumonia (defined by ICD-9-CM Code 507.0) and patients with a principal discharge diagnosis of sepsis (defined by ICD-9-CM codes 995.91, 995.92, 038, 038.0, 038.1, 038.10, 038.11, 038.12, 038.19, 038.2,038.3, 038.4, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49, 038.8, 038.9, and 785.52) or respiratory failure (defined by ICD-9-CM codes 518.81, 518.82. 518.84, and 799.1) and a secondary diagnosis of pneumonia coded as present on admission (POA). Patients who are transferred from one acute care facility to another must have a principal discharge diagnosis of pneumonia at both hospitals. The initial hospital for a transferred patient is designated as the responsible institution for the episode.[For reference, denominator for NQF endorsed measure on QPS: This claims-based measure can be used in either of two patient cohorts: (1) patients aged 65 years or older or (2) patients aged 18 years or older.The cohort includes admissions for patients discharged from the hospital with a principal discharge diagnosis of pneumonia and with a complete claims history for the 12 months prior to admission.]
Exclusions: The measure excludes index admissions for patients: 1. Discharged alive on the day of admission or the following day who were not transferred; 2. With inconsistent or unknown vital status or other unreliable demographic data; 3. Enrolled in the Medicare hospice program or VA hospice services any time in the 12 months prior to the index admission, including the first day of the index admission; and 4. Who were discharged against medical advice (AMA). After the above exclusions (#1-4) are applied, the measure randomly selects one index admission per patient per year for inclusion in the cohort. Each episode of care must be mutually independent with the same probability of the outcome. The probability of death increases with each subsequent admission and therefore the episodes of care are not mutually independent. For the three year combined data, when index admissions occur during the transition between measure reporting periods (June and July of each year) and both are randomly selected for inclusion in the measure, the measure only includes the June admission. The July admissions are excluded from the measure to avoid assigning a single death to two admissions.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: E0506 Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia hospitalization |
NQF Number (if applicable): 0506
Description: The measure estimates a hospital-level risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal diagnosis of pneumonia. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.
Numerator statement: The outcome for this measure is 30-day readmission. We define readmission as an inpatient admission for any cause, with the exception of certain planned readmissions, within 30 days from the date of discharge from the index pneumonia admission. If a patient has more than one unplanned admission within 30 days of discharge from the index admission, only the first one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.
Denominator statement: The denominator includes patients 18 and over hospitalized for pneumonia. The measure is currently publicly reported by CMS for those 65 years and older who are either Medicare FFS beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. In 2014, we propose updating our current definition of pneumonia to include patients with a principal discharge diagnosis of aspiration pneumonia (defined by ICD-9-CM Code 507.0) and patients with a principal discharge diagnosis of sepsis (defined by ICD-9-CM codes 995.91, 995.92, 038, 038.0, 038.1, 038.10, 038.11, 038.12, 038.19, 038.2,038.3, 038.4, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49, 038.8, 038.9, and 785.52) or respiratory failure (defined by ICD-9-CM codes 518.81, 518.82. 518.84, and 799.1) and a secondary diagnosis of pneumonia coded as present on admission (POA). To be included in the measure cohort used in public reporting, patients must meet the following additional inclusion criteria: enrolled in Part A and Part B Medicare for the 12 months prior to the date of admission, and enrolled in Part A during the index admission (this criterion does not apply to patients discharged from VA hospitals); not transferred to another acute care facility; and alive at discharge.[For reference, denominator for NQF endorsed measure in QPS: The target population for this measure is patients aged 18 years and older discharged from the hospital with a principal diagnosis of pneumonia with a complete claims history for the 12 months prior to admission. The measure is currently publicly reported by CMS for those 65 years and older who are either Medicare FFS beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals.As noted above, this measure can also be used for an all-payer population aged 18 years and older. We have explicitly tested the measure in both patients aged 18+ years and those aged 65+ years.]
Exclusions: For all cohorts, the measure excludes admissions for patients: -Discharged against medical advice (AMA); -Admitted with pneumonia within 30 days of discharge from a qualifying index admission (Admissions within 30 days of discharge of an index admission will be considered readmissions. No admission is counted as a readmission and an index admission. The next eligible admission after the 30-day time period following an index admission will be considered another index admission.) For Medicare FFS patients, the measure additionally excludes admissions for patients: -Without at least 30 days post-discharge enrollment in FFS Medicare
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: X3728 Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following acute myocardial infarction (AMI) hospitalization |
NQF Number (if applicable):
Description: This measure assesses days spent in acute care after discharge from an acute care setting for an acute myocardial infarction (AMI) hospitalization to provide a patient-centered assessment of the post-discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow-up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post-discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with AMI by collectively measuring a set of adverse outcomes that can occur post-discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post-discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day-count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk-standardized by subtracting the expected number of acute care days from the predicted number. The risk-standardized days of acute care are multiplied by 100 to represent risk-standardized days of events per 100 admissions.
Numerator statement: The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217-99220 or 99234-99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30-day post-discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30-day readmission measure for AMI.
Denominator statement: The target population for this measure is patients aged 65 years and older hospitalized for AMI and who are either Medicare Fee-for-Service (FFS) beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: -Having a principal discharge diagnosis of AMI; -Enrolled in FFS or are VA beneficiaries; -Aged 65 or over; -Discharged from non-federal acute care hospitals or VA hospitals alive; -Not transferred to another acute care facility; -and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of AMI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91.
Exclusions: This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post-discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non-VA hospitals). An additional exclusion criterion for the AMI cohort is that patients admitted and discharged on the same day are not included as an index admission.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3722 Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following heart failure hospitalization |
NQF Number (if applicable):
Description: This measure assesses days spent in acute care after discharge from an acute care setting for a heart failure hospitalization to provide a patient-centered assessment of the post-discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow-up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post-discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with heart failure by collectively measuring a set of adverse outcomes that can occur post-discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post-discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day-count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk-standardized by subtracting the expected number of acute care days from the predicted number. The risk-standardized days of acute care are multiplied by 100 to represent risk-standardized days of events per 100 admissions.
Numerator statement: The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217-99220 or 99234-99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30-day post-discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30-day readmission measure for heart failure.
Denominator statement: The target population for this measure is patients aged 65 years and older hospitalized for heart failure and who are either Medicare Fee-for-Service (FFS) beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: -Having a principal discharge diagnosis of heart failure; -Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65 or over; -Discharged from non-federal acute care hospitals or VA hospitals alive; -Not transferred to another acute care facility; -and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of heart failure International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9.
Exclusions: This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post-discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non-VA hospitals).
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3727 Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization |
NQF Number (if applicable):
Description: This measure assesses days spent in acute care after discharge from an acute care setting for a pneumonia hospitalization to provide a patient-centered assessment of the post-discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow-up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post-discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with pneumonia by collectively measuring a set of adverse outcomes that can occur post-discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post-discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day-count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk-standardized by subtracting the expected number of acute care days from the predicted number. The risk-standardized days of acute care are multiplied by 100 to represent risk-standardized days of events per 100 admissions.
Numerator statement: The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217-99220 or 99234-99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30-day post-discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30-day readmission measure for pneumonia.
Denominator statement: The target population for this measure is patients aged 65 years and older hospitalized for pneumonia and who are either Medicare Fee-for-Service (FFS) beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: -Having a principal discharge diagnosis of pneumonia; -Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65 or over; -Discharged from non-federal acute care hospitals or VA hospitals alive; -Not transferred to another acute care facility; -and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0, and 488.11; ICD-10-CM codes J120, J121, J122, J1281, J1289, J129, J13, J181, J150, J151, J14, J154, J154, J153, J154, J1520, J1521, J1521, Z16, J1529, J158, J155, J156, A481, J158, J159, J157, J160, J168, J180, J189, J1100, J129, J09119).
Exclusions: This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post-discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non-VA hospitals).
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3620 Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) |
NQF Number (if applicable):
Description: This measure estimates hospital-level, risk-standardized payments for a primary elective total THA/TKA episode of care starting with inpatient admission to a short term acute-care facility for Medicare fee-for-service (FFS) patients who are 65 years of age or older.
Numerator statement: Outcome: hospital-level, risk-standardized payment for Medicare patients for a primary elective total hip and/or knee arthroplasty episode of care. Payment timeframe: admission date through 90 days post-admission.
Denominator statement: Admissions for Medicare FFS patients: with qualifying THA/TKA procedure; Aged 65 or over; Admitted to non-federal acute care hospitals; Enrolled in Medicare Parts A and B for index and 12 months prior; Not transferred from acute care facility.
Exclusions: Patients without complete administrative data in the 90 days following the index admission, if alive 2) Patients with no payment information during the index admission 3) Patients discharged against medical advice (AMA) 4) Patients transferred to federal hospitals 5) Patients with more than two THA/TKA procedure codes during the admission
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims, Chronic Condition Data Warehouse (CCW), Other (please list in GTL comment field)
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3701 Hospital-Wide All-Cause Unplanned Readmission Hybrid eMeasure |
NQF Number (if applicable):
Description: This eMeasure estimates the hospital-level, risk-standardized rate of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge (RSRR). The eMeasure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts (grouped by discharge condition categories or procedure categories): surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology. The eMeasure also indicates the hospital standardized risk ratios (SRR) for each of these five specialty cohorts. This eMeasure is a re-engineering of measure 1789, the Hospital-Wide All-Cause Risk-Standardized Readmission Measure developed for patients 65 years and older using Medicare claims. This reengineered measure uses clinical data elements from patients’ electronic health records for risk adjustment in addition to claims data.
Numerator statement: The outcome for this measure is unplanned all-cause 30-day readmission. We defined a readmission as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an earlier, eligible index admission.
Denominator statement: Admissions for patients: Who are matched in the EHR/claims data; Enrolled in Medicare FFS; Aged 65 or over; Discharged from non-federal acute care hospitals; Discharged alive; Not transferred to an acute care facility; Enrolled in Part A for 12 mo prior
Exclusions: The measure excludes admissions for patients: •Admitted to Prospective Payment System (PPS)-exempt cancer hospitals Rationale: These hospitals care for a unique population of patients that cannot reasonably be compared to patients admitted to other hospitals •Without at least 30 days of post-discharge enrollment in FFS Medicare Rationale: The 30-day readmission outcome cannot be assessed in this group since claims data are used to determine whether a patient was readmitted. •Discharged against medical advice (AMA) Rationale: Providers did not have the opportunity to deliver full care and prepare the patient for discharge. •Admitted for primary psychiatric diagnoses Rationale: Patients admitted for psychiatric treatment are typically cared for in separate psychiatric or rehabilitation centers that are not comparable to acute care hospitals. •Admitted for rehabilitation Rationale: These admissions are not typically to an acute care hospital and are not for acute care. •Admitted for medical treatment of cancer Rationale: These admissions have a different mortality and readmission profile than the rest of the Medicare population, and outcomes for these admissions do not correlate well with outcomes for other admissions. Patients with cancer admitted for other diagnoses or for surgical treatment of their cancer remain in the measure.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Hybrid
Measure type: Outcome
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E1659 Influenza Immunization |
NQF Number (if applicable): 1659
Description: Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.
Numerator statement: Inpatient discharges who were screened for influenza vaccine status and were vaccinated prior to discharge if indicated.
Denominator statement: Acute care hospitalized inpatients age 6 months and older discharged during October, November, December, January, February or March.
Exclusions: Excluded patients consist of the following; Patients who expire prior to hospital discharge and patients with an organ transplant during the current hospitalization. See the 2a1.9 for ICD-9 and ICD-10 tables for transplants. Patients who have a Length of Stay greater than 120 days. Patients who are transferred or discharged to another acute care hospital. Patients who leave Against Medical Advice (AMA).[For reference, additional exclusion included for endorsed measure in QPS: Patients for whom vaccination was indicated, but supply had not been received by the hospital due to problems with vaccine production or distribution. ]
HHS NQS Priority: Best Practice of Healthy Living
HHS Data Source: Administrative Claims, Paper Medical Record
Measure type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: E0431 Influenza vaccination coverage among healthcare personnel (HCP) |
NQF Number (if applicable): 0431
Description: Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
Numerator statement: HCP in the denominator population who during the time from October 1 (or when the vaccine became available) through March 31 of the following year: (a) received an influenza vaccination administered at the healthcare facility, or reported in writing (paper or electronic) or provided documentation that influenza vaccination was received elsewhere; or (b) were determined to have a medical contraindication/condition of severe allergic reaction to eggs or to other component(s) of the vaccine, or history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination; or (c) declined influenza vaccination; or (d) persons with unknown vaccination status or who do not otherwise meet any of the definitions of the above-mentioned numerator categories. Numerators are to be calculated separately for each of the above groups.
Denominator statement: Number of HCP who are working in the healthcare facility for at least 1 working day between October 1 and March 31 of the following year, regardless of clinical responsibility or patient contact. Denominators are to be calculated separately for: (a) Employees: all persons who receive a direct paycheck from the reporting facility (i.e., on the facility’s payroll). (b) Licensed independent practitioners: include physicians (MD, DO), advanced practice nurses, and physician assistants only who are affiliated with the reporting facility who do not receive a direct paycheck from the reporting facility. (c) Adult students/trainees and volunteers: include all adult students/trainees and volunteers who do not receive a direct paycheck from the reporting facility.
Exclusions: None
HHS NQS Priority: Making Care Safer
HHS Data Source: National Healthcare Safety Network
Measure type: Process
Steward: Centers for Disease Control and Prevention
Endorsement Status: Endorsed
| MUC ID: E1523 In-hospital mortality following elective open repair of AAAs |
NQF Number (if applicable): 1523
Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers.
Numerator statement: Mortality following elective open repair of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
Denominator statement: All elective open repairs of asymptomatic AAAs in men with < 6 cm dia and women with < 5.5 cm dia AAAs
Exclusions: Exclusion Statement: = 6 cm minor diameter - men = 5.5 cm minor diameter - women Symptomatic AAAs that required urgent/emergent (non-elective) repair
HHS NQS Priority: Making Care Safer
HHS Data Source: Registry
Measure type: Outcome
Steward: The Society for Vascular Surgery
Endorsement Status: Endorsed
| MUC ID: X0351 Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Kidney/Urinary Tract Infection episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient with a kidney/urinary tract infection hospital admission. The Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the kidney/urinary tract infection treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to kidney/urinary tract infection across a provider’s eligible kidney/urinary tract infection episodes during the period of performance. A kidney/urinary tract infection episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s kidney/urinary tract infection episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Adminstrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X0352 Knee Replacement/ Revision Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Knee Replacement/Revision Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Knee Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a knee replacement/revision. The Knee Replacement/Revision Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Knee Replacement/Revision Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the knee replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Knee Replacement/Revision Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the knee replacement/revision across a provider’s eligible Knee Replacement/Revision episodes during the period of performance. A knee replacement/revision episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s knee replacement/revision episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0293 Medication Information |
NQF Number (if applicable): 0293
Description: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that medication information was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that medication information was communicated to the receiving FACILITY within 60 minutes of departure • Documentation regarding medication history • Allergies • Medications given (MAR)
Denominator statement: All emergency department patients who are transferred to another healthcare facility
Exclusions: All emergency department patients not discharged to another healthcare facility.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record, Prescription Drug Event Data Elements
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: E0514 MRI Lumbar Spine for Low Back Pain |
NQF Number (if applicable): 0514
Description: This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI.
Numerator statement: MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy.[For reference, additional numerator text for endorsed measure from QPS: The numerator measurement of prior conservative therapy is based on the claim date of the MRI of the lumbar spine from the denominator, with the prior conservative therapy within the defined time periods relative to each MRI lumbar spine claim (i.e., a patient can be included in the numerator count more than once, if the patient had more than one MRI lumbar spine procedure in the measurement period and the MRI lumbar spine procedure occurred on different days).]
Denominator statement: MRI of the lumbar spine studies with a diagnosis of low back pain on the imaging claim.[For reference, additional denominator text for endorsed measure from QPS: The diagnosis of low back pain must be on the MRI lumbar spine claim (i.e., the lumbar spine MRI must be billed with a low back pain diagnosis in one of the diagnoses fields on the claim). MRI lumbar spine studies without a diagnosis of low back pain on the claim are not included in the denominator count. If a patient had more than one MRI lumbar spine study for a diagnosis of low back pain on the same day only one study would be counted, but if a patient had multiple MRI lumbar spine studies with a diagnosis of low back pain on the claim during the measurement period each study would be counted (i.e., a patient can be included in the denominator count more than once).]
Exclusions: Indications for measure exclusion include any patients with the following procedures or diagnosis codes: • Patients with lumbar spine surgery in the 90 days prior to MRI: • Cancer (Within 12 months prior to MRI procedure. A cancer exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims) • Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims) • IV Drug Abuse: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.) • Neurologic Impairment: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.) • Human Immunodeficiency Virus (HIV): (Within 12 months prior to MRI procedure An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.) • Unspecified Immune Deficiencies: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.) • Intraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.)
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: S0138 National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome |
NQF Number (if applicable):
Description: CAUTI can be minimized by a collection of prevention efforts. These include reducing the number of unnecessary indwelling catheters inserted, removing indwelling catheters at the earliest possible time, securing catheters to the patient´s leg to avoid bladder and urethral trauma, keeping the urine collection bag below the level of the bladder, and utilizing aseptic technique for urinary catheter insertion. These efforts will result in decreased morbidity and mortality and reduce healthcare costs. Use of this measure to track CAUTIs through a nationalized standard for HAI monitoring, leads to improved patient outcomes and provides a mechanism for identifying improvements and quality efforts.
Numerator statement: Total number of observed healthcare-associated CAUTI among patients in bedded inpatient care locations (excluding patients in Level II or III neonatal ICUs).
Denominator statement: S.7. Denominator Statement: Total number of indwelling urinary catheter days for each location under surveillance for CAUTI during the data period. S.10. Denominator Exclusions: The following are not considered indwelling catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.
Exclusions: The following are not considered indwelling catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.
HHS NQS Priority: Making Care Safer
HHS Data Source: National Healthcare Safety Network
Measure type: Outcome
Steward: Centers for Disease Control and Prevention
Endorsement Status:
| MUC ID: S0139 National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome |
NQF Number (if applicable):
Description: CLABSI can be minimized through proper management of the central line. Efforts to improve central line insertion and maintenance practices, with early discontinuance of lines are recommended. These efforts result in decreased morbidity and mortality and reduced healthcare costs.
Numerator statement: Total number of observed healthcare-associated CLABSI among patients in bedded inpatient care locations.
Denominator statement: S.7. Denominator Statement: Total number of central line days for each location under surveillance for CLABSI during the data period. S.10. Denominator Exclusions: 1. Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are excluded as CLs. 2. Extracorporeal membrane oxygenation lines, femoral arterial catheters, intraaortic balloon pump devices, and hemodialysis reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines are excluded as CLs.
Exclusions: Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are excluded as CLs. 2. Extracorporeal membrane oxygenation lines, femoral arterial catheters, intraaortic balloon pump devices, and hemodialysis reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines are excluded as CLs.
HHS NQS Priority: Making Care Safer
HHS Data Source: National Healthcare Safety Network
Measure type: Outcome
Steward: Centers for Disease Control and Prevention
Endorsement Status:
| MUC ID: E1717 National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure |
NQF Number (if applicable): 1717
Description: Standardized infection ratio (SIR) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs)
Numerator statement: Total number of observed hospital-onset CDI Lab ID events among all inpatients in the facility, excluding well baby-nurseries and NICUs
Denominator statement: Total number of expected hospital-onset CDI LabID events, calculated using the facility´s number of inpatient days, bedsize, affiliation with medical school, microbiological test used to identify C. difficile, and community-onset CDI admission prevalence
Exclusions: Data from patients who are not assigned to an inpatient bed are excluded from the denominator counts, including outpatient clinic and emergency department visits. Additionally, data from well-baby nurseries and NICUs are excluded from the denominator count.
HHS NQS Priority: Making Care Safer
HHS Data Source: National Healthcare Safety Network
Measure type: Outcome
Steward: Centers for Disease Control and Prevention
Endorsement Status: Endorsed
| MUC ID: E1716 National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure |
NQF Number (if applicable): 1716
Description: Standardized infection ratio (SIR) of hospital-onset unique blood source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility
Numerator statement: Total number of observed hospital-onset unique blood source MRSA LabID events among all inpatients in the facility
Denominator statement: Total number of expected hospital-onset unique blood source MRSA LabID events, calculated using the facility´s number of inpatient days, bedsize, affiliation with medical school, and community-onset MRSA bloodstream infection admission prevalence rate.
Exclusions: Data from patients who are not assigned to an inpatient bed are excluded from the denominator counts. These include outpatient clinic and emergency department visits.
HHS NQS Priority: Making Care Safer
HHS Data Source: National Healthcare Safety Network
Measure type: Outcome
Steward: Centers for Disease Control and Prevention
Endorsement Status: Endorsed
| MUC ID: E0221 Needle biopsy to establish diagnosis of cancer precedes surgical excision/resection |
NQF Number (if applicable): 0221
Description: Percentage of patients presenting with AJCC Stage Group 0, I, II, or III disease, who undergo surgical excision/resection of a primary breast tumor who undergo a needle biopsy to establish diagnosis of cancer preceding surgical excision/resection.
Numerator statement: Patient whose date of needle biopsy precedes the date of surgery.
Denominator statement: Women with AJCC Stage 0, I, II, or II breast cancer undergoing surgery: • Women • Age 18 at time of diagnosis • Known or assumed first or only cancer diagnosis • Primary tumors of the breast • Epithelial invasive malignancy only • Surgically treated • Diagnosis and all or part of first course of treatment performed at the reporting facility
Exclusions: Exclusions: Men; not a first or only cancer diagnosis; non-epithelial tumors; metastatic disease (AJCC Stage IV); not treated surgically; died before surgery
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Registry
Measure type: Process
Steward: American College of Surgeons
Endorsement Status: Endorsed
| MUC ID: X3719 Normothermia Outcome |
NQF Number (if applicable): N/A
Description: This measure evaluates whether patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU
Numerator statement: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU
Denominator statement: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration
Exclusions: None
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record
Measure type: Intermediate Outcome
Steward: ASC Quality Collaboration
Endorsement Status: Not Endorsed
| MUC ID: E0205 Nursing Hours per Patient Day |
NQF Number (if applicable): 0205
Description: NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month. NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN,LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month. Measure focus is structure of care quality in acute care hospital units.
Numerator statement: Total number of productive hours worked by nursing staff with direct patient care responsibilities for each hospital inpatient unit during the calendar month.
Denominator statement: Denominator is the total number of patient days for each in-patient unit during the calendar month. Patient days must be from the same unit in which nursing care hours are reported.
Exclusions: Patient days from some non-reporting unit types, such as Emergency Department, peri-operative unit, and obstetrics, are excluded.
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Administrative Claims, Administrative Clinical Data, Facility Discharge Data, EHR, Paper Medical Record, Other (please list in GTL comment field)
Measure type: Structure
Steward: American Nurses Association
Endorsement Status: Endorsed
| MUC ID: E0296 Nursing Information |
NQF Number (if applicable): 0296
Description: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that nursing information was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that nursing information was communicated to the receiving facility within 60 minutes of departure • Assessments/ intervention/response • Impairments • Catheters • Immobilizations • Respiratory support • Oral limitations
Denominator statement: All emergency department patients who are transferred to another healthcare facility
Exclusions: All emergency department patients not discharged to another healthcare facility
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: EHR, Paper Medical Record, Prescription Drug Event Data Elements
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: X3698 O/ASPECS About Facility and Staff |
NQF Number (if applicable):
Description: Multi-item measure: P1: "When you arrived at this facility on the day of your procedure, did the check-in process run smoothly?" P2: "Was the facility clean?" P3: "Were the clerks and receptionists at the facility as helpful as you thought they should be?" P4: "Did the clerks and receptionists at the facility treat you with courtesy and respect?" P5: "Did the doctors, nurses and other staff treat you with courtesy and respect?" P6: "Did the doctors, nurses and other staff make sure you were as comfortable as possible?"
Numerator statement: Proportions of top box responses (YES) are calculated for each question. The proportions are then averaged over all questions in the multi-item measure. (P1+P2+P3+P4+P5+P6)/6
Denominator statement: See numerator statement.
Exclusions: Persons younger than 18 years having a surgery or procedure in a hospital outpatient surgery department or ambulatory surgery center, CPT code does not fall between 100021-69990 without Modifier 53 (procedure did not take place); discharged to hospice.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Patient Engagement/Experience
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3699 O/ASPECS Communication |
NQF Number (if applicable):
Description: Multi-item measure: P1: “Did your doctor or anyone from the facility give you all the information you needed about your procedure?” P2: “Did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?” P3: “Did the doctors, nurses and other staff explain things about your procedure in a way that was easy for you to understand?” P4 “Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand? P5: “Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?
Numerator statement: Proportions of top box responses (YES, YES DEFINITELY) are calculated for each question. P4 and P5 count only those who had anesthesia. These proportions are then averaged over all questions in the multi-item measure. (P1 + P2 + P3 + P4 + P5)/5
Denominator statement: See numerator statement.
Exclusions: Persons younger than 18 years having a surgery or procedure in a hospital outpatient surgery department or ambulatory surgery center, CPT code does not fall between 100021-69990 without Modifier 53 (procedure did not take place); discharged to hospice.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Patient Engagement/Experience
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3697 O/ASPECS Discharge and Recovery |
NQF Number (if applicable):
Description: Multi-item measure: P1: “Discharge instructions include things like symptoms you should watch out for after your procedure, instructions about your medicines, and home care. Before you left the facility, did you receive written discharge instructions?” P2: “Did your doctor or anyone from the facility prepare you for what to expect during your recovery?” P3: “Ways to control pain can include prescription medicine, over-the-counter pain relievers or ice packs, for example. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure” (of those that had pain as a result of the procedure). P4: “Before you left, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting” (of those that had either nausea or vomiting as a result of either your procedure or anesthesia). P5: “Before you left, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure” (of those that had bleeding as a result of the procedure). P6: “Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection (of those having signs of infection as a result of the procedure).
Numerator statement: Proportions of top box responses (YES, YES DEFINITELY) are calculated for each question. These proportions are then averaged over all questions in the multi-item measure. (P1 + P2 + P3 + P4 + P5+ P6)/6
Denominator statement: See numerator statement.
Exclusions: Persons younger than 18 years having a surgery or procedure in a hospital outpatient surgery department or ambulatory surgery center, CPT code does not fall between 100021-69990 without Modifier 53 (procedure did not take place); discharged to hospice.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Patient Engagement/Experience
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3702 O/ASPECS Overall Facility Rating |
NQF Number (if applicable):
Description: Survey Question: Using any number from 0 10 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?
Numerator statement: Number of respondents answering 9 or 10
Denominator statement: Number of respondents answering the survey question
Exclusions: Persons younger than 18 years having a surgery or procedure in a hospital outpatient surgery department or ambulatory surgery center, CPT code does not fall between 100021-69990 without Modifier 53 (procedure did not take place); discharged to hospice.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Patient Engagement/Experience
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: X3703 O/ASPECS Recommend |
NQF Number (if applicable):
Description: Survey question: Would you recommend this facility to your friends and family? Response options: Definately no, Probably no, Probably yes, Definately yes.
Numerator statement: Number of respondents answering “Definately yes”.
Denominator statement: Number of respondents answering the survey question
Exclusions: Persons younger than 18 years having a surgery or procedure in a hospital outpatient surgery department or ambulatory surgery center, CPT code does not fall between 100021-69990 without Modifier 53 (procedure did not take place); discharged to hospice.
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Survey
Measure type: Patient Engagement/Experience
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E2104 Paired Measures 0702 and 0703; Intensive Care Unit (ICU) Length-of-Stay (LOS) and Intensive Care: In-hospital mortality rate |
NQF Number (if applicable): 2104
Description: Paired Measure: Intensive Care Unit (ICU) Length-of-Stay (LOS) paired with Intensive Care: In-hospital mortality rate. E0702 Measure Description: For all patients admitted to the ICU, total duration of time spent in the ICU until time of discharge; both observed and risk-adjusted LOS reported with the predicted LOS measured using the Intensive Care Outcomes Model - Length-of-Stay (ICOMLOS). E0703 Measure Description: For all adult patients admitted to the intensive care unit (ICU), the percentage of patients whose hospital outcome is death; both observed and risk-adjusted mortality rates are reported with predicted rates based on the Intensive Care Outcomes Model - Mortality (ICOMmort).[Note: Measure submitted for endorsement; in process]
Numerator statement: E0702 Numerator Statement: For all eligible patients admitted to the ICU, the time at discharge from ICU (either death or physical departure from the unit) minus the time of admission (first recorded vital sign on ICU flow sheet) E0703 Numerator Statement: Total number of eligible patients whose hospital outcome is death
Denominator statement: E0702 Denominator Statement: Total number of eligible patients who are discharged (including deaths and transfers) E0703 Denominator Statement: Total number of eligible patients who are discharged (including deaths and transfers)
Exclusions: E0702 Exclusions: <18 years of age at time of ICU admission, ICU readmission, <4 hours in ICU, primary admission due to trauma, burns, or immediately post-CABG, admitted to exclude myocardial infarction (MI) and subsequently found without MI or any other acute process requiring ICU care, transfers from another acute care hospital E0703 Exclusions: <18 years of age at time of ICU admission, ICU readmission, <4 hours in ICU, primary admission due to trauma, burns, or immediately post-CABG, admitted to exclude myocardial infarction (MI) and subsequently found without MI or any other acute process requiring ICU care, transfers from another acute care hospital
HHS NQS Priority: Making Care Safer
HHS Data Source: EHR, Paper Medical Record
Measure type: Outcome
Steward: Philip R. Lee Institute for Health Policy Studies
Endorsement Status: Not Endorsed
| MUC ID: X3689 Participation in a Patient Safety Culture Survey |
NQF Number (if applicable):
Description: Participation in a patient safety culture survey involves a) What is the name of the survey? b) How frequently is the survey administered? c) Which staff positions complete the survey? d) Are survey results reported to a centralized location? e) What is the survey response rate?
Numerator statement: The facility/hospital conducts a patient safety culture survey among physicians, nurses, technicians, and support staff
Denominator statement: None
Exclusions: None
HHS NQS Priority: Making Care Safer
HHS Data Source: Other (please list in GTL comment field)
Measure type: Structure
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0141 Patient fall rate |
NQF Number (if applicable): 0141
Description: All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days and Unassisted Falls per 1000 Patient Days. (Total number of falls / Patient days) X 1000 Measure focus is safety. Target population is adult acute care inpatient and adult rehabilitation patients.
Numerator statement: Total number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the calendar month X 1000. Target population is adult acute care inpatient and adult rehabilitation patients. Eligible unit types include adult critical care, adult step-down, adult medical, adult surgical, adult medical-surgical combined, critical access, adult rehabilitation in-patient.
Denominator statement: Patient days by hospital unit during the calendar month. Included Populations: •Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on eligible inpatient units for all or part of a day on the following unit types: •Adult critical care, step-down, medical, surgical, medical-surgical combined, critical access, and adult rehabilitation units. •Patients of any age on an eligible reporting unit are included in the patient day count
Exclusions: Other unit types (e.g., pediatric, psychiatric, obstetrical, etc.)
HHS NQS Priority: Making Care Safer
HHS Data Source: EHR, Paper Medical Record
Measure type: Outcome
Steward: American Nurses Association
Endorsement Status: Endorsed
| MUC ID: E0294 Patient Information |
NQF Number (if applicable): 0294
Description: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that patient information was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that patient information was communicated to the receiving FACILITY within 60 minutes of departure • Patient name • Address • Date of birth • Gender • Significant other contact information • Health insurance information
Denominator statement: All emergency department patients who are transferred to another healthcare facility
Exclusions: All emergency department patients not discharged to another healthcare facility
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: E2158 Payment-Standardized Medicare Spending Per Beneficiary (MSPB) |
NQF Number (if applicable): 2158
Description: The MSPB Measure assesses the cost of services performed by hospitals and other healthcare providers during an MSPB hospitalization episode, which comprises the period immediately prior to, during, and following a patient’s hospital stay. Beneficiary populations eligible for the MSPB calculation include Medicare beneficiaries enrolled in Medicare Parts A and B who were discharged from short-term acute hospitals during the period of performance.[Note: Description differs from older version of measure listed on QPS.]
Numerator statement: The numerator for a hospital’s MSPB Measure is the hospital’s average MSPB Amount, which is defined as the sum of standardized, risk-adjusted spending across all of a hospital’s eligible episodes divided by the number of episodes for that hospital.
Denominator statement: The denominator for a hospital’s MSPB Measure is the median MSPB Amount across all episodes nationally.
Exclusions: None
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Cost/ Resource Use
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: X3740 Performing an intraoperative rectal examination at the time of prolapse repair |
NQF Number (if applicable):
Description: Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior prolapse.
Numerator statement: Number of patients in whom an intraoperative rectal examination was performed and documented. These would be identified by chart review or entry into the Registry.
Denominator statement: Denominator = All patients undergoing apical or posterior pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis : 56800, 56810 (introital repair/ perineoplasty)
Exclusions: Patients who have undergone prior total proctectomy Patients who have exclusively anterior compartment repairs
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Paper Medical Record, Registry
Measure type: Process
Steward: American Urogynecologic Society
Endorsement Status: Not Endorsed
| MUC ID: X3752 Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury |
NQF Number (if applicable):
Description: Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
Numerator statement: Numerator is the number of patients in whom an intraoperative cystoscopy was performed to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
Denominator statement: The number of patients undergoing hysterectomy for pelvic organ prolapse. Hysterectomy (identified by CPT codes) performed for the indication of pelvic organ prolapse (identified by supporting ICD9/ICD10 codes) The prolapse codes for ICD9 -> ICD-10 are detailed below, respectively: 618.01 -> N81.10, Cystocele, midline 618.02 -> N81.12, Cystocele, lateral 618.03 -> N81.0, Urethrocele 618.04 -> N81.6, Rectocele 618.05 -> N81.81, Perineocele 618.2 -> N81.2, Incomplete uterovaginal prolapse 618.3 -> N81.3, Complete uterovaginal prolapse 618.4 -> N81.4, Uterovaginal prolapse, unspecified 618.6 -> N81.5, Vaginal enterocele 618.7 -> N81.89, Old laceration of muscles of pelvic floor 618.81 -> N81.82, incompetence or weakening of pubocervical tissue 618.82 -> N81.83, incompetence or weakening of rectovaginal tissue 618.83 -> N81.84, pelvic muscle wasting CPT codes for hysterectomy are: 57530 Trachelectomy 58150 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo-Urethrocystopexy (e.g. Marshall-Marchetti-Krantz, Burch) 58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58260 Vaginal Hysterectomy, for Uterus 250 G or Less 58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s) 58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele 58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control 58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele 58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy 58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele 58290 Vaginal Hysterectomy, for Uterus Greater than 250 G 58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele 58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type) 58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele 58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less 58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G 58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less 58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G 58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) 58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less 58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) 58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G 58573 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)
Exclusions: None
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Paper Medical Record, Registry
Measure type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Not Endorsed
| MUC ID: X1970 Perinatal Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in vertex position delivered by cesarean section |
NQF Number (if applicable):
Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position who are delivered by a cesarean section. PC O2 is also part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding).
Numerator statement: Patients with cesarean sections
Denominator statement: Nulliparous patients delivered of a live term singleton newborn in vertex presentation
Exclusions: Excluded Populations: ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations and other presentations as defined in Appendix A, Table 11.09 Less than 8 years of age Greater than or equal to 65 years of age Length of Stay >120 days Enrolled in clinical trials Gestational Age < 37 weeks or UTD
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: EHR
Measure type: Outcome
Steward: The Joint Commission
Endorsement Status: Not Endorsed
| MUC ID: E0465 Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy |
NQF Number (if applicable): 0465
Description: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery. [Note: Description is for update to NQF endorsed measure and differs from specifications provided in QPS]
Numerator statement: Patients over age 18 undergoing carotid endarterectomy who received anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists within 48 hours prior to the initiation of surgery AND are prescribed this medication at hospital discharge following surgery. [Note:Numerator is for update to NQF endorsed measure and differs from specifications provided in QPS]
Denominator statement: Patients over age 18 undergoing carotid endarterectomy.
Exclusions: Patients with known intolerance to anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists, or those on heparin or other intravenous anti-coagulants; patients with active bleeding or undergoing urgent or emergent operations or endarterectomy combined with cardiac surgery. Patients with known intolerance to anti-platelet agents such as aspirin or aspirin-like agents, or P2y12 antagonists, or those on or other intravenous anti-coagulants; patients with active bleeding or undergoing urgent or emergent operations or endarterectomy combined with cardiac surgery. [Note: Exclusion is for update to NQF endorsed measure and differs from specifications provided in QPS]
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Claims, Paper Medical Record, Registry
Measure type: Process
Steward: The Society for Vascular Surgery
Endorsement Status: Endorsed
| MUC ID: X3809 Perioperative Temperature Management |
NQF Number (if applicable):
Description: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Numerator statement: Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Denominator statement: All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer
Exclusions: Exclusions: Patients undergoing: Cardiopulmonary bypass: 00561, 00562, 00563, 00566, 00567, 00580 Regional nerve block: 01958, 01960, 01967, 01991, 01992 Monitored anesthesia care: any CPT code with -QS modifier Exceptions: Documentation of one of the following medical reason(s) for not achieving at least one body temperature greater than or equal to 35.5 degrees Celsius or 95.9 degrees Fahrenheit within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Emergency cases Intentional hypothermia
HHS NQS Priority: Making Care Safer
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Outcome
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: E0295 Physician Information |
NQF Number (if applicable): 0295
Description: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that physician information was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that physician information was communicated to the receiving FACILITY within 60 minutes of departure • Physician or practitioner history and physical • Physician or practitioner orders and plan
Denominator statement: All emergency department patients who are transferred to another healthcare facility
Exclusions: All emergency department patients not transferred to another healthcare facility
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: E0219 Post breast conservation surgery irradiation |
NQF Number (if applicable): 0219
Description: Percentage of female patients, age 18-69, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC stage I, II, or III, receiving breast conserving surgery who receive radiation therapy within 1 year (365 days) of diagnosis.
Numerator statement: Radiation therapy to the breast is initiated within 1 year (365 days) of the date of diagnosis
Denominator statement: Include, if all of the following characteristics are identified: Women Age 18-69 at time of diagnosis Known or assumed to be first or only cancer diagnosis Primary tumors of the breast Epithelial malignancy only AJCC Stage I, II, or III Surgical treatment by breast conservation surgery (surgical excision less than mastectomy) All or part of 1st course of treatment performed at the reportingfacility.[For reference, additional text included on denominator in endorsed measure’s description in QPS: Known to be alive within 1 year (365 days) of diagnosis]
Exclusions: Exclude, if any of the following characteristics are identified: Men Under age 18 at time of diagnosis; Over age 69 at time of diagnosis; Second or subsequent cancer diagnosis; Tumor not originating in the breast; Non-epithelial malignancies; Stage 0, in-situ tumor; Stage IV, metastatic tumor; None of 1st course therapy performed at reporting facility; Died within 12 months (365 days) of diagnosis
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record, Registry
Measure type: Process
Steward: American College of Surgeons
Endorsement Status: Endorsed
| MUC ID: X3810 Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) |
NQF Number (if applicable):
Description: Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.
Numerator statement: All age patients who have been cared for by an anesthesia practitioner and are transferred directly from the procedure room to post-anesthesia care unit (PACU) for post-procedure care for whom a checklist or protocol which includes the key transfer of care elements is utilized. • All age patients under the care of an anesthesia practitioner AND • Are transferred to another practitioner in a PACU following completion of the anesthetic care AND a transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is used. The key handoff elements that must be included in the transition of care include: 1. Identification of patient 2. Identification of responsible practitioner (PACU nurse or advanced practitioner) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issues/concerns. 6. Expectations/Plans for the early post-procedure period. 7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team
Denominator statement: All age patients who are cared for by an anesthesia practitioner and are transferred directly from the procedure room to the PACU upon completion of the anesthetic. • All age patients under the care of an anesthesia practitioner AND • Who are transferred directly to the PACU at the completion of the anesthetic. • This measure does not include transfer of care during an anesthetic or to the ICU.
Exclusions: All age patients who have been cared for by an anesthesia practitioner who are not admitted from the operating room directly to a PACU.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Process
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: X3807 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) |
NQF Number (if applicable): N/A
Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member
Numerator statement: Patients who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member Definition: The key handoff elements that must be included in the transfer of care protocol or checklist include: 1. Identification of patient, key family member(s) or patient surrogate 2. Identification of responsible practitioner (primary service) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure 6. Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration 7. Opportunity for questions and acknowledgement of understanding of report from the receiving ICU team
Denominator statement: All patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an ICU directly from the anesthetizing location Any procedure including surgical, therapeutic or diagnostic
Exclusions: None
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Process
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: X3808 Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents |
NQF Number (if applicable): N/A
Description: Percentage of patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to surgical start time
Numerator statement: Patients who receive aspirin 24 hours prior to surgical start time Definition: Patient reports taking aspirin OR hospital staff administered aspirin The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.
Denominator statement: All patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia
Exclusions: Exclusions: None Exceptions: Documentation of medical reasons for not receiving aspirin 24 hours prior to anesthesia start time (e.g., risks of preoperative aspirin therapy are greater than the risks of withholding aspirin, other medical reasons)
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Process
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: X3806 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination |
NQF Number (if applicable): N/A
Description: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively
Numerator statement: Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively Definition: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to): • 5-hydroxytryptamine (5-HT3) receptor antagonists • dexamethasone • phenothiazine • phenylethylamines • butyrophenones • antihistamines • anticholinergics The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.
Denominator statement: All patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for PONV Definition: Risk factors for PONV are: 1. female gender, 2. history of PONV or a history of motion sickness, 3. non-smoker, and 4. intended administration of opioids for post-operative analgesia Any procedure including surgical, therapeutic or diagnostic This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.
Exclusions: Exclusions: None Exceptions: Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (e.g., intolerance or other medical reason)
HHS NQS Priority: Patient and Family Engagement
HHS Data Source: Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Process
Steward: American Society of Anesthesiologists
Endorsement Status: Not Endorsed
| MUC ID: E0297 Procedures and Tests |
NQF Number (if applicable): 0297
Description: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that procedure and test information was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another Healthcare Facility whose medical record documentation indicated that procedure and test information was communicated to the receiving FACILITY within 60 minutes of departure • Tests & procedures done • Tests & procedure results sent
Denominator statement: All emergency department patients who are transferred to another Healthcare Facility
Exclusions: ED admissions not transferred to another Healthcare facility.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record, Prescription Drug Event Data Elements
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| MUC ID: E0704 Proportion of Patients Hospitalized with AMI that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) |
NQF Number (if applicable): 0704
Description: Percent of adult population aged 18 – 65 years who were admitted to a hospital with acute myocardial infarction (AMI), were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Define PACs during each time period as one of three types: (A) PACs during the Index Stay (Hospitalization): (1) PACs related to the anchor condition: The index stay is regarded as having a PAC if during the index hospitalization the patient develops one or more complications such as cardiac arrest, ventricular fibrillation, cardiogenic shock, stroke, coma, acute post-hemorrhagic anemia etc. that may result directly due to AMI or its management. (2) PACs due to Comorbidities: The index stay is also regarded as having a PAC if one or more of the patient’s controlled comorbid conditions is exacerbated during the hospitalization (i.e. it was not present on admission). Examples of these PACs are diabetic emergency with hypo- or hyperglycemia, tracheostomy, mechanical ventilation, pneumonia, lung complications gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting Patient Safety Failures: The index stay is regarded as having a PAC if there are one or more complications related to patient safety issues. Examples of these PACs are septicemia, meningitis, other infections, phlebitis, deep vein thrombosis, pulmonary embolism or any of the CMS-defined hospital acquired conditions (HACs). (B) PACs during the 30-day post discharge period: (1) PACs related to the anchor condition: Readmissions and emergency room visits during the 30-day post discharge period after an AMI are considered as PACs if they are for angina, chest pain, another AMI, stroke, coma, heart failure etc. (2) PACs due to Comorbidities: Readmissions and emergency room visits during the 30-day post discharge period are also considered PACs if they are due to an exacerbation of one or more of the patient’s comorbid conditions, such as a diabetic emergency with hypo- or hyperglycemia, pneumonia, lung complications, tracheostomy, mechanical ventilation etc. (3) PACs suggesting Patient Safety Failures: Readmissions or emergency room visits during the 30-day post discharge period are considered PACs if they are due to sepsis, infections, phlebitis, deep vein thrombosis, or for any of the CMS-defined hospital acquired conditions (HACs).
Numerator statement: Outcome: Potentially avoidable complications (PACs) in patients hospitalized for AMI occurring during the index stay or in the 30-day post-discharge period.
Denominator statement: Adult patients aged 18 – 65 years who had a relevant hospitalization for AMI (with no exclusions) and were followed for one-month after discharge
Exclusions: Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those that have any form of cancer, ESRD (end-stage renal disease), transplants such as lung or heart-lung transplant or complications related to transplants, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the AMI measure if they are considered not relevant to AMI care or are for major surgical services that suggests that AMI may be a comorbidity associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.
HHS NQS Priority: Making Care Safer
HHS Data Source: Administrative Claims, Other (please list in GTL comment field)
Measure type: Outcome
Steward: Bridges to Excellence
Endorsement Status: Endorsed
| MUC ID: E0708 Proportion of Patients Hospitalized with Pneumonia that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) |
NQF Number (if applicable): 0708
Description: Percent of adult population aged 18 – 65 years who were admitted to a hospital with Pneumonia, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs).[Note: Additional information about measure description included for endorsed measure in QPS.]
Numerator statement: Outcome: Potentially avoidable complications (PACs) in patients hospitalized for pneumonia occurring during the index stay or in the 30-day post-discharge period.
Denominator statement: Adult patients aged 18 – 65 years who had a relevant hospitalization for Pneumonia (with no exclusions) and were followed for one-month after discharge.
Exclusions: Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those that have any form of cancer (especially cancer of lung and bronchus), thalassemia, sickle-cell disease, ESRD (end-stage renal disease), transplants such as lung or heart-lung transplant or complications related to transplants, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the Pneumonia measure if they are considered not relevant to pneumonia care or are for major surgical services that suggests that pneumonia may be a comorbidity associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.
HHS NQS Priority: Making Care Safer
HHS Data Source: Administrative Claims, EHR, Other (please list in GTL comment field)
Measure type: Outcome
Steward: Bridges To Excellence
Endorsement Status: Endorsed
| MUC ID: E0705 Proportion of Patients Hospitalized with Stroke that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period) |
NQF Number (if applicable): 0705
Description: Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Define PACs during each time period as one of three types: (A) PACs during the Index Stay (Hospitalization): (1) PACs related to the anchor condition: The index stay is regarded as having a PAC if during the index hospitalization for stroke the patient develops one or more complications such as hypertensive encephalopathy, malignant hypertension, coma, anoxic brain damage, or respiratory failure etc. that may result directly from stroke or its management. (2) PACs due to Comorbidities: The index stay is also regarded as having a PAC if one or more of the patient’s controlled comorbid conditions is exacerbated during the hospitalization (i.e. it was not present on admission). Examples of these PACs are diabetic emergency with hypo- or hyperglycemia, pneumonia, lung complications, acute myocardial infarction, gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting Patient Safety Failures: The index stay is regarded as having a PAC if there are one or more complications related to patient safety issues. Examples of these PACs are septicemia, meningitis, other infections, phlebitis, deep vein thrombosis, pulmonary embolism or any of the CMS-defined hospital acquired conditions (HACs). (B) PACs during the 30-day post discharge period: (1) PACs related to the anchor condition: Readmissions and emergency room visits during the 30-day post discharge period after a stroke are considered as PACs if they are for hypertensive encephalopathy, malignant hypertension, respiratory failure, coma, anoxic brain damage etc. (2) PACs due to Comorbidities: Readmissions and emergency room visits during the 30-day post discharge period are also considered PACs if they are due to an exacerbation of one or more of the patient’s comorbid conditions, such as a diabetic emergency with hypo- or hyperglycemia, pneumonia, lung complications, acute myocardial infarction, acute renal failure etc. (3) PACs suggesting Patient Safety Failures: Readmissions or emergency room visits during the 30-day post discharge period are considered PACs if they are due to sepsis, infections, deep vein thrombosis, pulmonary embolism, or for any of the CMS-defined hospital acquired conditions (HACs).
Numerator statement: Outcome: Potentially avoidable complications (PACs) in patients hospitalized for stroke occurring during the index stay or in the 30-day post-discharge period.
Denominator statement: Adult patients aged 18 – 65 years who had a relevant hospitalization for stroke (with no exclusions) and were followed for one-month after discharge.
Exclusions: Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those with that have any form of cancer, ESRD (end-stage renal disease), transplants such as lung or heart-lung transplant or complications related to transplants, intracranial trauma, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the stroke measure if they are considered not relevant to stroke care or are for major surgical services that suggests that stroke may be a comorbidity or complication associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.
HHS NQS Priority: Making Care Safer
HHS Data Source: Administrative Claims, EHR
Measure type: Outcome
Steward: Bridges to Excellence
Endorsement Status: Endorsed
| MUC ID: X3743 Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair |
NQF Number (if applicable):
Description: Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery
Numerator statement: Total number of patient's receiving a bladder injury at the time of surgery to repair a pelvic organ prolapse with repair during the procedure or subsequently up to 1 month post-surgery
Denominator statement: Denominator = All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis
Exclusions: Exclusions: • Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy Exceptions: Patients having concurrent surgery involving bladder neoplasia or otherwise to treat a bladder specific problem
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Paper Medical Record, Registry, Other (please list in GTL comment field)
Measure type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Not Endorsed
| MUC ID: X3744 Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair |
NQF Number (if applicable):
Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscous at the time of index surgery that is recognized intraoperative or within 1 month after surgery
Numerator statement: The number of patients receiving a major viscous injury with repair at the time of initial surgery or subsequently up to 1 month postoperatively
Denominator statement: Denominator = All patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 45560, 57250, 57210 (posterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis
Exclusions: Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Registry
Measure type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Not Endorsed
| MUC ID: X3813 Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair |
NQF Number (if applicable):
Description: Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery
Numerator statement: Number of patients receiving a ureter injury at the time of a pelvic organ prolapse procedure, with repair during the procedure or subsequently up to 1 month postoperatively
Denominator statement: Denominator = All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: 57280, 57282, 57283, 57425 (colpopexies) 57240, 57284, 57285, 57423 (anterior repairs) 57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair) 58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) 58400, uterine suspension 57120 colpocleisis
Exclusions: Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy
HHS NQS Priority: Making Care Safer
HHS Data Source: Claims, Paper Medical Record, Registry, Survey
Measure type: Outcome
Steward: American Urogynecologic Society
Endorsement Status: Not Endorsed
| MUC ID: E0204 Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract) |
NQF Number (if applicable): 0204
Description: NSC-12.1 - Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit. NSC-12.2 - Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit. NSC-12.3 - Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit. NSC-12.4 - Percentage of total productive nursing hours worked by contract or agency staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities by hospital unit. Note that the skill mix of the nursing staff (NSC-12.1, NSC-12.2, and NSC-12.3) represent the proportions of total productive nursing hours by each type of nursing staff (RN, LPN/LVN, and UAP); NSC-12.4 is a separate rate. Measure focus is structure of care quality in acute care hospital units.
Numerator statement: Four separate numerators are as follows: RN hours – Productive nursing care hours worked by RNs with direct patient care responsibilities for each hospital in-patient unit during the calendar month. LPN/LVN hours – Productive nursing care hours worked by LPNs/LVNs with direct patient care responsibilities for each hospital in-patient unit during the calendar month. UAP hours – Productive nursing care hours worked by UAP with direct patient care responsibilities for each hospital in-patient unit during the calendar month. Contract or agency hours – Productive nursing care hours worked by nursing staff (contract or agency staff) with direct patient care responsibilities for each hospital in-patient unit during the calendar month.
Denominator statement: Denominator is the total number of productive hours worked by employee or contract nursing staff with direct patient care responsibilities (RN, LPN/LVN, and UAP) for each hospital in-patient unit during the calendar month.
Exclusions: Same as numerator; nursing staff with no direct patient care responsibilities are excluded. Excluded nursing staff: Persons whose primary responsibility is administrative in nature. Specialty teams, patient educators, or case managers who are not assigned to a specific unit. Unit secretaries or clerks, monitor technicians, and other with no direct patient care responsibilities.[For reference, exclusions for NQF endorsed measure from QPS: Same as numerator; nursing staff with no direct patient care responsibilities are excluded.]
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Administrative Claims, Administrative Clinical Data, Hybrid, Other (please list in GTL comment field)
Measure type: Structure
Steward: American Nurses Association
Endorsement Status: Endorsed
| MUC ID: X0353 Spine Fusion/ Refusion Clinical Episode-Based Payment Measure |
NQF Number (if applicable):
Description: The Spine Fusion/Refusion Clinical Episode-Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value-based incentive payments. Spine Fusion/Refusion episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post-acute care) a patient who receives a spine fusion/refusion. The Spine Fusion/Refusion Clinical Episode-Based Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Spine Fusion/Refusion Clinical Episode-Based Payment Measure includes Medicare payments only for services that are clinically related to the spine fusion/refusion performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode-based measure are standardized and risk-adjusted.
Numerator statement: The numerator of the Spine Fusion/Refusion Clinical Episode-Based Payment Measure is the sum of a provider’s risk-adjusted spending and the preadmission and post-discharge medical services that are clinically related to the spine fusion/refusion across a provider’s eligible spine fusion/refusion episodes during the period of performance. A spine fusion/refusion episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.
Denominator statement: A count of the provider’s spine fusion/refusion episodes during the period of performance.
Exclusions: The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare-covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.
HHS NQS Priority: Making Care Affordable
HHS Data Source: Adminstrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E1663 SUB-2 Alcohol Use Brief Intervention Provided or Offered. SUB-2a Alcohol Use Brief Intervention Received. |
NQF Number (if applicable): 1663
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.[For reference, additional description for endorsed measure included in QPS: 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).]
Numerator statement: SUB-2 The number of patients who received or refused a brief intervention. SUB-2a The number of patients who received a brief intervention.
Denominator statement: The number of hospitalized inpatients 18 years of age and older who screen positive for unhealthy alcohol use or an alcohol use disorder (alcohol abuse or alcohol dependence).
Exclusions: Patients less than 18 years of age • Patient who are cognitively impaired • Patients who refused or were not screened for alcohol use during the hospital stay • Patients who have a duration of stay less than or equal to three days or greater than 120 days • Patients receiving Comfort Measures Only documented[For reference, exclusion for endorsed measure in QPS: The denominator has 4 exclusions as follows:• Patients less than 18 years of age• Patient who are cognitively impaired• Patients who refused or were not screened for alcohol use during the hospital stay• Patients who have a length of stay less than or equal to one day and greater than 120 days]
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Administrative Clinical Data, Paper Medical Record
Measure type: Process
Steward: The Joint Commission
Endorsement Status: Endorsed
| MUC ID: E0513 Thorax CT: Use of Contrast Material |
NQF Number (if applicable): 0513
Description: This measure calculates the ratio of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both). The measure is calculated based on a one year window of claims data.
Numerator statement: The number of thorax CT studies with and without contrast (combined studies).[For reference, numerator for NQF endorsed measure in QPS: The number of thorax CT studies with and without contrast (herein, ´combined studies´).Sum of global and technical units associated with the following CPT code:71270 – CT Thorax with and without ContrastA technical unit can be identified by a modifier code of TC. A global unit can be identified by the absence of a TC or 26 modifier code.Thorax CT studies can be billed separately for the technical and professional components, or billed globally, which includes both the professional and technical components.Professional component claims will outnumber technical component claims due to over-reads.To capture all outpatient volume facility claims, typically paid under the OPPS/APC methodology, global and TC claims should be considered, and to avoid double counting of professional component claims (i.e., 26 modifier).]
Denominator statement: The number of thorax CT studies performed (with contrast, without contrast or both with and without contrast).[For reference, denominator for NQF endorsed measure in QPS: The number of thorax CT studies performed (with contrast, without contrast, or both with and without contrast) on Medicare beneficiaries within a 12-month time window.Sum of global and technical units for the following CPT codes:71250 - CT thorax without contrast71260 – CT thorax with contrast71270 – CT thorax with and without contrast]
Exclusions: None
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Endorsed
| MUC ID: X1234 Timely Evaluation of High-Risk Individuals in the Emergency Department |
NQF Number (if applicable):
Description: Median time from emergency department (ED) arrival to provider evaluation for individuals triaged at the two highest levels based on a five-level triage system (e.g., triaged as “immediate” or “emergent”).
Numerator statement: Measure Observation 1: Median time (in minutes) from ED arrival to Qualified Provider Contact for Emergency Department patients triaged with an acuity level of "1-immediate". Measure Observation 2: Median time (in minutes) from ED arrival to Qualified Provider Contact for Emergency Department patients triaged with an acuity level of "2-emergent".
Denominator statement: Measure Population: Any emergency department encounter for which individuals with a triage score of “1-Immediate” or "2-Emergent" based on a 5-level triage system.
Exclusions: ED visit for trauma
HHS NQS Priority: Making Care Safer
HHS Data Source: EHR
Measure type: Process
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0648 Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) |
NQF Number (if applicable): 0648
Description: Percentage of patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge
Numerator statement: Patients for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge
Denominator statement: All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care
Exclusions: Patients who died Patients who left against medical advice (AMA) or discontinued care
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record
Measure type: Process
Steward: American Medical Association - Physician Consortium for Performance Improvement
Endorsement Status: Endorsed
| MUC ID: E1656 TOB-3 Tobacco Use Treatment Provided or Offered at Discharge AND TOB-3a Tobacco Use Treatment at Discharge |
NQF Number (if applicable): 1656
Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age an older to whom tobacco use 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 tobacco use treatment at discharge. Treatment at discharge includes a referral to outpatient counseling and a prescription for one of the FDA-approved tobacco cessation medications. TOB-3 Patients identified as tobacco product users within the past 30 days who were referred to or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication upon discharge. TOB-3a Patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication upon discharge as well as those who were referred to outpatient counseling and had reason for not receiving a prescription for medication.[For reference, description of endorsed measure in QPS: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age an older to whom tobacco use 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 tobacco use treatment at discharge. Treatment at discharge includes a referral to outpatient counseling and a prescription for one of the FDA-approved tobacco cessation medications. Refer to section 2a1.10 Stratification Details/Variables for the rationale for the addition of the subset measure. These measures are intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening; TOB 2 Tobacco Use Treatment Provided or Offered During the Hospital Stay; TOB-4 Tobacco Use: Assessing Status After Discharge).]
Numerator statement: TOB-3: The number of patients who received or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication at discharge TOB-3a: The number of patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication at discharge.
Denominator statement: The number of hospitalized inpatients 18 years of age and older identified as current tobacco users
Exclusions: The exclusions to this measure are as follows: 1. Patients less than 18 years of age 2. Patients who are cognitively impaired 3. Patients who are not current tobacco users 4. Patients who refused or were not screened for tobacco use status during the hospital stay (as tobacco status cannot be known) 5. Patients who have a length of stay less than or equal to one day or greater than 120 days 6. Patients who expired during the hospital stay 7. Patients who left against medical advice 8. Patients discharged/transferred to another hospital for inpatient care 9. Patients discharged/transferred to a federal health care facility 10. Patients discharged/transferred to hospice 11. Patients who do not reside in the United States
HHS NQS Priority: Effective Prevention and Treatment
HHS Data Source: Administrative Clinical Data, Facility Discharge Data, Paper Medical Record
Measure type: Process
Steward: The Joint Commission
Endorsement Status: Endorsed
| MUC ID: E0349 Transfusion Reaction (PSI 16) |
NQF Number (if applicable): 0349
Description: The count of medical and surgical discharges for patients age greater than or equal to 18 or in MDC 14 with ICD-9-CM code for transfusion reaction in any secondary diagnosis field.
Numerator statement: Discharges 18 years and older or in MDC 14 with ICD-9-CM codes for transfusion reaction in any secondary diagnosis field of all medical and surgical discharges defined by specific DRGs or MS-DRGs[For reference, additional information included in numerator for NQF endorsed measure in QPS: See Patient Safety Indicators Appendices:- Appendix B – Medical Discharge DRGs - Appendix C – Medical Discharge MS-DRGs - Appendix D – Surgical Discharge DRGs- Appendix E – Surgical Discharge MS-DRGsLink to PSI appendices: http://qualityindicators.ahrq.gov/Downloads/Software/SAS/V43/TechnicalSpecifications/PSI%20Appendices.pdf Exclude cases:-with principal diagnosis of transfusion reaction or secondary diagnosis present on admission-with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)]
Denominator statement: N/A
Exclusions: None
HHS NQS Priority: Making Care Safer
HHS Data Source: Administrative Claims
Measure type: Outcome
Steward: Agency for Healthcare Research & Quality
Endorsement Status: Endorsed
| MUC ID: E0647 Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) |
NQF Number (if applicable): 0647
Description: Percentage of patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements
Numerator statement: Patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements: Inpatient Care • Reason for inpatient admission, AND • Major procedures and tests performed during inpatient stay and summary of results, AND • Principal diagnosis at discharge Post-Discharge/ Patient Self-Management • Current medication list, AND • Studies pending at discharge (e.g., laboratory, radiological), AND • Patient instructionsAdvance Care Plan • Advance directives or surrogate decision maker documented OR • Documented reason for not providing care plan Contact Information/Plan for Follow-up Care • 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND • Contact information for obtaining results of studies pending at discharge, AND • Plan for follow-up care, AND • Primary physician, other health care professional, or site designated for follow-up care[Note: Numerator differs from posted MUC list based on NQF staff analysis]
Denominator statement: All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care.
Exclusions: Patients who died. Patients who left against medical advice (AMA) or discontinued care.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record
Measure type: Process
Steward: American Medical Association - Physician Consortium for Performance Improvement
Endorsement Status: Endorsed
| MUC ID: X3720 Unplanned Anterior Vitrectomy |
NQF Number (if applicable): N/A
Description: This measure evaluates the number of cataract surgery patients who have an unplanned anterior vitrectomy
Numerator statement: All cataract surgery patients who had an unplanned anterior vitrectomy
Denominator statement: All cataract surgery patients
Exclusions: None
HHS NQS Priority: Making Care Safer
HHS Data Source: Paper Medical Record
Measure type: Outcome
Steward: ASC Quality Collaboration
Endorsement Status: Not Endorsed
| MUC ID: X607 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache |
NQF Number (if applicable):
Description: This measure calculates the percentage of Emergency Department (ED) visits for atraumatic headache with a coincident brain computed tomography (CT) study for Medicare beneficiaries.
Numerator statement: Of ED visits identified in the denominator, visits with a coincident brain CT study (i.e., brain CT studies on the same day for the same patient).
Denominator statement: ED patients with a primary diagnosis of atraumatic headache.
Exclusions: This measure uses exceptions from the numerator, rather than exclusions from the denominator The following secondary diagnosis codes are exceptions from the numerator: -Anticoagulant use -Lumbar puncture -Dizziness or paresthesia -Lack of coordination -Subarachnoid hemorrhage -Complicated or thunderclap headache -Focal neurologic deficit -Pregnancy -Trauma -HIV -Tumor(s)/mass(es) -Imaging studies for ED patients admitted to the hospital"
HHS NQS Priority: Making Care Affordable
HHS Data Source: Administrative Claims
Measure type: Efficiency
Steward: Centers for Medicare & Medicaid Services
Endorsement Status: Not Endorsed
| MUC ID: E0292 Vital Signs |
NQF Number (if applicable): 0292
Description: Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that the entire vital signs record was communicated to the receiving FACILITY within 60 minutes of departure
Numerator statement: Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that the entire vital signs record was communicated to the receiving facility within 60 minutes of departure • Pulse • Respiratory rate • Blood pressure • Oxygen saturation • Temperature • Glasgow score (where appropriate)
Denominator statement: All emergency department patients who are transferred to another healthcare facility.
Exclusions: All emergency department patients not discharged to another healthcare facility.
HHS NQS Priority: Communication and Care Coordination
HHS Data Source: Administrative Claims, EHR, Paper Medical Record, Prescription Drug Event Data Elements
Measure type: Process
Steward: University of Minnesota Rural Health Research Center
Endorsement Status: Endorsed
| Medicare Shared Savings Program |
Program Type: MSSP is a combination pay for reporting and pay for performance program.
Incentive Structure: Option for one-sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year) or a two-sided risk model (sharing of savings and losses for all three years).
Program Goals: “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.”
Critical Program Objectives:
Program Update: For 2014, the MSSP program has 33 measures that may be
submitted through a CMS web interface, currently the group practice reporting
(GPRO) web interface, calculated by CMS from internal and claims data, and
collected through a patient and caregiver experience of care
survey.
The 2015 Physician Fee Schedule final rule includes the
following changes:
| Ambulatory Surgical Centers Quality Reporting Program |
Program Type: Pay for Reporting – Performance information is currently reported to the Centers for Medicare & Medicaid Services (CMS) but it is expected to be publicly available in the future.
Incentive Structure: Pay for Reporting – Performance information is currently reported to the Centers for Medicare & Medicaid Services (CMS) but it is expected to be publicly available in the future.
Program Goals:
Critical Program Objectives:
Program Update:
| Hospital-Acquired Condition (HAC) Reduction Program |
Program Type: Pay-for-Performance and Public Reporting. HAC scores will be reported on the Hospital Compare website beginning December 2014.
Incentive Structure:
Program Goals:
Critical Program Objectives:
Program Update:
| Hospital Value-Based Purchasing Program |
Program Type: Pay for Performance
Incentive Structure: Medicare bases a portion of hospital
reimbursement on performance through the Hospital Value-Based Purchasing Program
(VBP). Medicare withholds its regular hospital reimbursements from all hospitals
paid under its inpatient prospective payment system (IPPS) to fund a pool of
VBP incentive payments. The amount withheld from reimbursements increases over
time:
Program Goals:
Critical Program Objectives:
Program Update:
| Hospital Readmission Reduction Program |
Program Type: Pay for Performance and Public Reporting – Payments are based on information publicly reported on the Hospital Compare website.
Incentive Structure: Diagnosis-related group (DRG) payment rates will be reduced based on a hospital’s ratio of actual to expected readmissions. The maximum payment reduction is 2 percent, and will increase to 3% beginning October 2014.
Program Goals:
Critical Program Objectives:
Program Update:
| Inpatient Psychiatric Facilities Quality Reporting Program |
Program Type: Pay for Reporting – Information will be reported on the Hospital Compare website.
Incentive Structure:
Program Goals:
Critical Program Objectives:
Program Update:
| Inpatient Quality Reporting Program |
Program Type: Pay-for-Reporting and Public Reporting. A subset of the measures in the program are publicly reported on the Hospital Compare web site.
Incentive Structure: Hospitals that do not report data on the required measures will receive a 2 percent reduction in their annual Medicare payment update.
Program Goals:
Critical Program Objectives:
Program Update:
| Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) |
Program Type: Pay for Reporting. The Medicare and Medicaid EHR Incentive Programs provide incentives to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology
Incentive Structure: For the Medicare Incentive Program (hospitals), incentive payments began in 2011 and are comprised of an Initial Amount, Medicare Share, and Transition Factor. The CAH EHR Incentive payment is based on a formula for Allowable Costs and the Medicare Share. The Medicaid Incentive program includes an Overall EHR Amount and Medicaid Share. Medicare payment penalties will take effect in 2015 for providers who are eligible but do not participate. Payment penalties do not apply to Medicaid. For Stage 1, eligible facilities must report on all 15 total clinical quality measures. For Stage 2 (2014 and beyond) eligible facilities must report on 16 clinical quality measures that cover 3 of the National Quality Strategy domains. Measures are selected from a set of 29 clinical quality measures that includes the 15 measures from Stage 1.
Program Goals:
Critical Program Objectives:
Program Update:
| Hospital Outpatient Quality Reporting Program |
Program Type: Pay for Reporting – Information on measures is reported on the Hospital Compare website.
Incentive Structure: Hospitals that do not report data on the required measures will receive a 2 percent reduction in their annual Medicare payment update.
Program Goals:
Critical Program Objectives:
Program Update:
| PPS-Exempt Cancer Hospital Quality Reporting Program |
Program Type: Reporting: Information will be publicly reported beginning in 2014.
Incentive Structure: There is currently no financial incentive for the 11 hospitals in this program to report quality measures. CMS plans to create an incentive structure in the future.
Program Goals:
Critical Program Objectives:
Program Update: