Measure Applications Partnership
Hospital Workgroup Discussion Guide

Notes for Measure Deliberations
Version Number: 5.6
Meeting Date: December 14, 2017

Full Agenda

Day 1  
8:30 AM   Breakfast
9:00 AM   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Melissa Mariñelarena, Senior Director, NQF

9:15 AM   CMS Opening Remarks and Review of Meaningful Measures Framework
Pierre Yong, CMS

9:45 AM   MAP Pre-Rulemaking Approach and Voting Instructions
Kate McQueston, Project Manager, NQF

10:00 AM   Overview of the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Program and Opportunity for Public Comment on Measures Under Consideration
10:55 AM   Pre-Rulemaking Input for ESRD QIP
• MUC17-176: Medication Reconciliation for Patients Receiving Care at Dialysis Facilities • MUC17-241: Percentage of Prevalent Patients Waitlisted (PPPW) • MUC17-245: Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR)
Programs under consideration:
  1. Medication Reconciliation for Patients Receiving Care at Dialysis Facilities (MUC ID: MUC17-176)
    • Description: Percentage of patient-months for which medication reconciliation* was performed and documented by an eligible professional.** * “Medication reconciliation” is defined as the process of creating the most accurate list of all home medications that the patient is taking, including name, indication, dosage, frequency, and route, by comparing the most recent medication list in the dialysis medical record to one or more external list(s) of medications obtained from a patient or caregiver (including patient-/caregiver-provided “brown bag” information), pharmacotherapy information network (e.g., Surescripts), hospital, or other provider. ** For the purposes of medication reconciliation, “eligible professional” is defined as: physician, RN, ARNP, PA, pharmacist, or pharmacy technician.
    • Preliminary analysis summary
      • Contribution to program measure set:This NQF endorsed measure addresses two priority areas for the ESRD-QIP program, safety and care coordination. The measure addresses a safety issue (medication reconciliation) that is not currently included in the program measure set.
      • Impact on quality of care for patients:This measure encourages dialysis facilities to perform and document medication reconciliation for their patients. Medication reconciliation is a critical safety issue for all patients, but particularly patients with end-stage renal disease (ESRD). Individuals with ESRD frequently require 10 or more medications and take an average of 17-25 doses per day.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  2. Percentage of Prevalent Patients Waitlisted (PPPW) (MUC ID: MUC17-241)
    • Description: This measure tracks the percentage of patients at each dialysis facility who were on the kidney or kidney-pancreas transplant waiting list. Results are averaged across patients prevalent on the last day of each month during the reporting year.
    • Preliminary analysis summary
      • Contribution to program measure set:This fully developed measure addresses an important quality gap for dialysis facilities. This measure should be submitted for NQF endorsement and review.
      • Impact on quality of care for patients:This measure would encourage dialysis facilities to ensure that patients remain healthy, and complete any ongoing testing activities required to remain on the waitlist.
    • Preliminary analysis result: Conditional Support for Rule Making
    • Notes:





  3. Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) (MUC ID: MUC17-245)
    • Description: This measure tracks the number of incident patients at the dialysis facility under the age of 75 listed on the kidney or kidney-pancreas transplant waitlist or who received living donor transplants within the first year of initiating dialysis.
    • Preliminary analysis summary
      • Contribution to program measure set:This fully developed measure addresses an important quality gap for dialysis facilities. This measure should be submitted for NQF endorsement and review.
      • Impact on quality of care for patients:This measure would encoruage dialysis facilities to ensure that patients receive support for transplant waitlisting process and to optimize the health and functional status of patients in order to increase their candidacy for transplant waitlisting.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





10:55 AM   Break
11:10 AM   Overview of the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:20 AM   Pre-Rulemaking Input for PCHQR
• MUC17-178: 30-Day Unplanned Readmissions for Cancer Patients
Programs under consideration:
  1. 30-Day Unplanned Readmissions for Cancer Patients (MUC ID: MUC17-178)
    • Description: 30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which all adult cancer patients covered as Fee-for-Service Medicare beneficiaries have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.”
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed and tested, and has received endorsement from NQF. It fills a current gap in the PPS-Exempt Cancer Hospital Quality Reporting Program by addressing unplanned readmissions of cancer patients.
      • Impact on quality of care for patients:Preventing cancer patient readmissions will improve the quality of care for cancer patients, improve healthoutcome, and reduce unessisary utlization of healthcare resources.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





11:40 AM   Overview of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:50 AM   Pre-Rulemaking Input for ASCQR
• MUC17-233: Hospital Visits following General Surgery Ambulatory Surgical Center Procedures
Programs under consideration:
  1. Hospital Visits following General Surgery Ambulatory Surgical Center Procedures (MUC ID: MUC17-233)
    • Description: The measure assesses ASC general surgery procedure quality using the outcome of hospital visits -- including emergency department (ED) visits, observation stays, and unplanned inpatient admissions -- within 7 days of the procedure performed at an ASC.
    • Preliminary analysis summary
      • Contribution to program measure set:This is a fully developed measure that addresses an important health outcome for patients receiving care at ASC general surgery centers. This measure should be sumbitted and reviewed for NQF endorsement.
      • Impact on quality of care for patients:This measure would encourage ASCs to implement strategies to reduce unplanned hospital visits following general surgery procedures.
    • Preliminary analysis result: Conditional Support for Rule Making
    • Notes:





12:20 PM   Overview of the Hospital Outpatient Quality Reporting Program (HOQR) and Opportunity for Public Comment on Measures Under Consideration
12:30 PM   Pre-Rulemaking Input for HOQR
• MUC17-223: Lumbar Spine Imaging for Low Back Pain
Programs under consideration:
  1. Lumbar Spine Imaging for Low Back Pain (MUC ID: MUC17-223)
    • Description: This measure calculates the percentage of CT (computed tomography) or MRI (magnetic resonance imaging) studies of the lumbar spine 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: 1. Claim(s) for physical therapy in the 60 days preceding the lumbar spine CT or MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine CT or MRI. 3. Claim(s) for evaluation and management in the period > 28 days and < 60 days preceding the lumbar spine CT or MRI.
    • Preliminary analysis summary
      • Contribution to program measure set:The measure is currently in the Hospital Outpatient Quality Reporting (HOQR) program. The NQF Musculoskeletal Standing Committee agreed that the measure does not meet the validity subcriterion. The measure lost endorsement in 2017.
      • Impact on quality of care for patients:Inappropriate use of imaging is problematic because it subjects patients to unnecessary harms such as radiation exposure and unnecessary treatment, yet it is not associated with improved outcomes. The intent of this measure is to reduce inappropriate imaging for LBP in the absence of “red flags” that can indicate that back pain is caused by a serious, underlying pathology.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





1:00 PM   Lunch
1:45 PM   Overview of the Hospital Inpatient Quality Reporting (HIQR) Program and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use) and Opportunity for Public Comment on Measures Under Consideration
1:55 PM   Pre-Rulemaking Input for HIQR
• MUC17-210: Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events • MUC17-195: Hospital-Wide All-Cause Risk Standardized Mortality Measure • MUC17-196: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure
Programs under consideration:
  1. Hospital-Wide All-Cause Risk Standardized Mortality Measure (MUC ID: MUC17-195)
    • Description: This measure estimates hospital-level, risk-standardized mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. This is a claims-based version of the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed and specified and compliments the existing CMS Hospital-Wide All-Cause Risk-Standardized Readmission Measure (NQF #1789). Testing results should demonstrate reliability and validity at the facility level in the acute care setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce the number of patient deaths (from any cause) within 30 days after admission, including in-hospital deaths.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  2. Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (MUC ID: MUC17-196)
    • Description: This measure estimates hospital-level, risk-standardized mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. The measure is referred to as a hybrid because it will use Medicare fee-for-service (FFS) administrative claims to derive the cohort and outcome, and claims and clinical electronic health record (EHR) data for risk adjustment.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed and specified and compliments the existing CMS Hospital-Wide All-Cause Risk-Standardized Readmission Measure (NQF #1789). Testing results should demonstrate reliability and validity at the facility level in the acute care setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce the number of patient deaths (from any cause) within 30 days after admission, including in-hospital deaths.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  3. Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events (MUC ID: MUC17-210)
    • Description: This measure will assess opioid related adverse respiratory events (ORARE) in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid related adverse respiratory events that occur in the hospital setting, using a valid method that reliably allows comparison across hospitals.
    • Preliminary analysis summary
      • Contribution to program measure set:Currently, this measure has not been tested in enough hospitals to assess measure reliability across hospitals; however, testing results should demonstrate reliability and validity at the facility level in the hospital setting. The developer has indicated that this measure is anticipated for November 2018 submission to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce opioid-related adverse respiratory events, a servious reportable event.
    • Preliminary analysis result: Revise and Resubmit
    • Notes:





3:00 PM   Overview of Hospital-Acquired Condition (HAC) Reduction Program and Discussion of Future Measures
Reena Duseja, CMS Joseph Clift, CMS

3:30 PM   Input on Measure Removal Criteria
4:10 PM   Public Comment
4:20 PM   MAP Rural Health Introduction and Presentation
Karen Johnson, Senior Director, NQF

4:40 PM   Summary of Day and Next Steps
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Desmirra Quinnonez, Project Analyst, NQF

5:00 PM   Adjourn