Day 1 |
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8:30 AM |
Breakfast |
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9:00 AM |
Welcome, Introductions, Disclosures of Interest, and
Review of Meeting Objectives |
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Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters,
MAP Hospital Workgroup Co-Chair Melissa Mariñelarena, Senior Director, NQF
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9:15 AM |
CMS Opening Remarks and Review of Meaningful Measures
Framework |
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Pierre Yong, CMS
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9:45 AM |
MAP Pre-Rulemaking Approach and Voting
Instructions |
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Kate McQueston, Project Manager, NQF
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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 |
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10:55 AM |
Pre-Rulemaking Input for ESRD QIP |
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• 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) |
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Programs under consideration:
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- 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:
- 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:
- 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:
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10:55 AM |
Break |
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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 |
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11:20 AM |
Pre-Rulemaking Input for PCHQR |
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• MUC17-178: 30-Day Unplanned Readmissions for Cancer Patients |
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Programs under consideration:
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- 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:
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11:40 AM |
Overview of the Ambulatory Surgery Center Quality
Reporting (ASCQR) Program and Opportunity for Public Comment on Measures
Under Consideration |
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11:50 AM |
Pre-Rulemaking Input for ASCQR |
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• MUC17-233: Hospital Visits following General Surgery Ambulatory
Surgical Center Procedures |
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Programs under consideration:
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- 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:
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12:20 PM |
Overview of the Hospital Outpatient Quality
Reporting Program (HOQR) and Opportunity for Public Comment on Measures
Under Consideration |
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12:30 PM |
Pre-Rulemaking Input for HOQR |
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• MUC17-223: Lumbar Spine Imaging for Low Back Pain |
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Programs under consideration:
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- 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:
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1:00 PM |
Lunch |
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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 |
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1:55 PM |
Pre-Rulemaking Input for HIQR |
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• 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 |
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Programs under consideration:
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- 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:
- 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:
- 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:
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3:00 PM |
Overview of Hospital-Acquired Condition (HAC)
Reduction Program and Discussion of Future Measures |
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Reena Duseja, CMS Joseph Clift, CMS
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3:30 PM |
Input on Measure Removal Criteria |
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4:10 PM |
Public Comment |
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4:20 PM |
MAP Rural Health Introduction and Presentation
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Karen Johnson, Senior Director, NQF
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4:40 PM |
Summary of Day and Next Steps |
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Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters,
MAP Hospital Workgroup Co-Chair Desmirra Quinnonez, Project Analyst, NQF
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5:00 PM |
Adjourn |
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