NON-PQRS MEASURES

All of the measures below qualify for PQRS credit. Those labeled “Non-PQRS” were developed by OBERD QCDR and approved by CMS for use in the 2016 PQRS reporting program.

OBERD 1: Back Pain: Mental Health Assessment

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: The percentage of patients at least 18 years of age and younger than 80 with a diagnosis of back pain for whom documentation of a mental health assessment is present in the OBERD QCDR prior to intervention or when pain lasts more than 6 weeks.

DENOMINATOR: Back pain patients at least 18 years of age and younger than 80 who meet either of the following criteria:

• Evidence of back surgery or epidural steroid injection, or
• More than six weeks pain duration

NUMERATOR: The number of patients with at least one mental health assessment during the eligible episode

RATIONALE: Pain is the leading symptom with which patients present at spine clinics, and chronic pain is a concomitant of depression. Quality of care will benefit if this linkage is explicitly addressed

OBERD 2: Back Pain: Patient Reassessment

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with back pain with documentation that the physician conducted reassessment of both of the following within four to six weeks of their initial back pain visit or of a surgical procedure date:

• Pain AND
• Functional status

DENOMINATOR: The total patient sample for patients at least 18 years of age and younger than 80

NUMERATOR:

• Pain Reassessment: The number of patients with documentation of reassessment of pain within four to six weeks of their initial back pain visit or of a surgical procedure date.
• Functional Status Reassessment: The number of patients with documentation of reassessment of functional status within four to six weeks of their initial back pain visit or of a surgical procedure date.

RATIONALE: Pain is the leading symptom with which patients present at spine clinics. Pain reassessment is necessary if conservative treatment tried first, and surgery without pain relief is a low-quality service

OBERD 3: Back Pain: Shared Decision Making

TYPE: Process

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with back pain with whom a physician or other clinician reviewed the range of treatment options, including alternatives to surgery prior to surgery. To demonstrate shared decision making, there must be documentation of audio-visual educational material or a discussion between the physician and patient that includes all of the following

• Treatment choices, including alternatives to surgery;
• Risks and benefits;
• Evidence of effectiveness

DENOMINATOR: Patients at least 18 years of age and younger than 80 who had surgery for back pain

NUMERATOR: The number of patients who had surgery, with documentation of audio-visual educational material or a discussion between the physician and the patient prior to surgery, which includes alternatives to surgery, risks and benefits and evidence of effectiveness.

EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

RATIONALE: This is the minimum requirement for patient centered care.

OBERD 4: Pain Assessment and Follow-Up

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

DENOMINATOR: Patients 18 years of age and older on the date of the encounter

NUMERATOR: Patient’s pain assessment is documented through discussion with the patient including the use of a standardized tool(s) AND a follow-up plan is documented when pain is present.

EXCLUSIONS/EXCEPTIONS:

• Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools
• Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

RATIONALE: Pain is the leading symptom with which patients present at spine clinics. It is well established that pain can be measured on numerical scales, and this simple monitoring device should not be omitted.

OBERD 5: Back Pain: Surgical Timing

TYPE: Process

QUALITY DOMAIN: Efficiency and Cost Reduction

DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more without documentation of red flags who had surgery within the first six weeks of back pain onset (overuse measure, lower performance is better).

DENOMINATOR: Patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more who have had back surgery

NUMERATOR: The number of patients with a surgical intervention to treat back pain within the first six weeks of pain

EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

RATIONALE: Conservative treatment, which suggests avoiding a rush to surgery, must be balanced with patient wishes and degree of suffering. It is valuable for a provider to track his timing versus common standards.

OBERD 6: Orthopedic Pain: Mental Health Assessment

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: Percentage of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery who received a mental health assessment

DENOMINATOR: Number of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery

NUMERATOR: Number of patients of age 18-80 presenting with pain from an orthopedic condition often treated with surgery who received a mental health assessment prior to surgery

RATIONALE: This is a straight-forward generalization of NQF-316 from back conditions to other orthopedic conditions.

OBERD 7: Orthopedic Pain: Patient Reassessment

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with orthopedic pain with documentation that the physician conducted reassessment of both of the following within four to six weeks of their initial orthopedic visit or orthopedic surgical procedure date:

• Pain AND
• Functional status

DENOMINATOR: The total patient sample for patients at least 18 years of age and younger than 80 presenting with orthopedic pain

NUMERATOR:

• Pain Reassessment: The number of patients with documentation of reassessment of pain within four to six weeks of their initial orthopedic visit or of a surgical procedure date.
• Functional Status Reassessment: The number of patients with documentation of reassessment of functional status within four to six weeks of their initial orthopedic visit or of a surgical procedure date.

RATIONALE: This is a straight-forward generalization of NQF-306 from back conditions to other orthopedic conditions.

OBERD 8: Orthopedic Pain: Shared Decision Making

TYPE: Process

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

DESCRIPTION: Percentage of patients at least 18 years of age and younger than 80 with orthopedic pain with whom a physician or other clinician reviewed the range of treatment options, including alternatives to surgery prior to surgery. To demonstrate shared decision making, there must be documentation of a discussion between the physician and the patient that includes all of the following.

• Treatment choices, including alternatives to surgery;
• Risks and benefits;
• Evidence of effectiveness

DENOMINATOR: Patients at least 18 years of age and younger than 80 who had orthopedic surgery

NUMERATOR: The number of patients who had orthopedic surgery, with documentation that a clinician and the patient discussed treatment options prior to surgery, including alternatives to surgery, risks and benefits and evidence of effectiveness

EXCLUSIONS/EXCEPTIONS: This measure is applicable only for physicians who perform surgery.

RATIONALE: This is a straight-forward generalization of NQF-420 from back conditions to other orthopedic conditions.

OBERD 9: Orthopedic Pain: Assessment and follow-up

TYPE: Process

QUALITY DOMAIN: Communication and Care Coordination

DESCRIPTION: Percentage of patients aged 18 years and older with documentation of a pain assessment including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

DENOMINATOR: Patients 18 years of age and older on the date of the encounter who presented with orthopedic pain at initial encounter

NUMERATOR: Number of patients with documented pain assessment including the use of a standardized tool(s) AND a follow-up plan is documented when pain is present.

RATIONALE: This is a straight-forward generalization of NQF-316 from back conditions to other orthopedic conditions.

OBERD 10: Quality of Life (VR-12 or Promis Global 10) Monitoring

TYPE: Process

QUALITY DOMAIN: Effective Clinical Care

DESCRIPTION: Percentage of patients for whom a quality of life assessment is collected by means of a Patient Reported Outcome instrument which permits standardized assessment of patient physical and mental health status over time

DENOMINATOR: Number of patients age 18 or older

NUMERATOR: Number of patients age 18 or older completing a VR-12 or Promis Global 10 survey on one or more occasions during reporting period

RATIONALE: Quality of life follow-up is fundamental to meaningful health care quality improvement. Such a process is already required for 2014 EHR Incentives in cases of TKA and THA. The two forms selected here are recommended (in CMS66v2 and CMS56v2) and both permit comparisons with national norms. VR-12 permits a finer-grained risk assessment (comorbidities, age, etc.) and the calculation of a utility score (VR-6D) which has been used, inter alia, in the evaluation of the Medicare Advantage plans

OBERD 11: Quality of Life (VR-12 or Promis Global 10) Outcomes

QUALITY DOMAIN: Effective Clinical Care

TYPE: Outcome

DESCRIPTION: Tracking change in health-related quality of life scores at regular intervals following an initial baseline assessment which occurred prior to an intervention. Data will be retained for reference and use for at least 7 years. A score is recorded for each administration of the PRO instrument during a measurement period, as is each intervention. For convenience, the accumulating data for a patient presented in several different ways, including

• graph of all scores plotted against time, with each intervention marked on the time axis;
• a plot of each score against interval since intervention to permit easy aggregation of scores of all patients:
• plots similar to the above but showing each score minus initial score, to reflect changes from baseline;
• bar graphs showing the change since last score;
• tables which collect the foregoing information for all patients of the provider in CSV format for further analysis Risk-adjusted versions of the foregoing whenever appropriate methods exist.

DENOMINATOR: Risk adjustment factor as appropriate

NUMERATOR: Raw scores

RATIONALE: Supplementing clinician observations and functional PROs with HRQoL evaluation by the patient provides a more complete picture of the quality of medical interventions. The two alternatives offered here have already been recommended in CMS66v2 and CMS56v2 for monitoring knee and hip arthroscopy respectively. The VR-12 permits calculation of a utility score, the VR-6D, which places all medical specialties on the same scale. VR-12 has been employed by both CMS and the VA for a number of years and has been administered to millions of individuals.  The PROMIS approach, based on item response theory and driven off of well-researched item banks, offers another option of growing importance. It incorporates extensive normative data (t-scores are calculated) and it has shown the ability to predict utility scores.

OBERD 12: CG-CAHPS Adult Visit Composite Tracking

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Process

DESCRIPTION: Percentage of all patients age 18 or older answering sufficiently many questions to address the 4 operationally defined CG-CAHPS composites

DENOMINATOR: Number of patients of age 18 or older

NUMERATOR: Number of patients age 18 or older completing at least one CG-CAHPS Adult Visit survey including responses to the questions comprising the following composites:

• Getting Timely Appointments, Care, and Information;
• How Well Providers Communicate With Patients;
• Helpful, Courteous, and Respectful Office Staff;
• Follow-up on Test Results

RATIONALE: The use of CG-CAHPS is explicitly recognized by PQRS, replacing the discontinued PQRS-321 measure. Additional information is scheduled for release in Spring 2014, but is not available at this writing. The measure proposed here is intended to encourage the administration of CG-CAHPS to all patients at each visit and to ensure that attention is focused on the actionable items in the survey, as summarized in four of the composites. The Adult Visit is the recommended form for three reasons. First, in speaking to the most recent visit, the experience is more clearly in mind; second, the responses are more easily used and evaluated by providers because it speaks to the current situation; and, third, because the 6-month or 12-month data can be approximated by compiling the last-visit information.

OBERD 13: Orthopedic Functional and Pain Level Outcomes

TYPE: Outcome

QUALITY DOMAIN: Effective Clinical Care

DESCRIPTION: Functional changes, including pain level changes, as a result of interventions on particular joints and with particular diagnoses will be addressed in the same way as QoL scores are handled in item 11 above, except that the provider is permitted to choose any PRO instrument validated for the joint in question.

DENOMINATOR: Risk adjustment factor as appropriate

NUMERATOR: Raw score

RATIONALE: Not specifying the forms to use has the disadvantages of small sample sizes and missed opportunities for comparison of providers. However, it is proposed that there should be a measure which brings the wisdom of the doctor into the process and which preserves the ability of the doctor to build upon data which has been gathered in the past.

OBERD 14: Orthopedic 3-Month Surgery Follow-up

QUALITY DOMAIN: Effective Clinical Care

Type: Process

DESCRIPTION: The measurement is the percent of patients receiving both a pre-operative and a post-operative administration of a PRO instrument validated for measuring functional status of orthopedic surgery patients. The pre-op must be administered no more than two weeks prior to surgery and the post-op must be administered within two-weeks of the three month anniversary of the surgery.

DENOMINATOR: All patients age 18 or older who received surgery between Jan 15 and Sept 15 OR who received surgery between Jan 1 and Jan 15 and have a pre-op available OR who received a surgery between Sept 15 and Oct 15 and have a post-op available

NUMERATOR: Patients in the denominator who have both a pre-op and post-op administration of the same validated instrument, such that the pre-op was administered no more than two weeks prior to surgery and the post-op was administered within two-weeks of the three month anniversary of the surgery.

RATIONALE: This process measure elucidates the extent to which changes in functional status of patients receiving surgical intervention are being tracked. The protocol chosen is designed to provide the maximum information for systematic quality improvement, employing a validated PRO instrument. The three-month follow-up period is very common in surgical practice, and can reasonably be accomplished within a yearlong measurement period for a high percentage of patients. The protocol specifies that the data required must be collected within two weeks of the nominal end-points of the follow-up period: pre-op may precede surgery by up to two weeks, and post-op may occur roughly 2.5 to 3.5 months later. This flexibility means that if surgery occurs near the beginning or end of the measurement period, valid data gathering may fall outside of the measurement period for some patients. Such patients are excluded from the denominator by an exclusion and two exceptions, expressed as “OR” conditions in the denominator definition above.

OBERD 15: Orthopedic 3-Month Surgery Outcome

TYPE: Outcome

QUALITY DOMAIN: Effective Clinical Care

Type: Outcome:

DESCRIPTION: This measure reports the average change in score for all patients whose functional status can be measured by a particular validated PRO instrument, over a three-month period following surgery. Pre-op and post-op definitions are the same as in OBERD 14.

PATIENT POPULATION: All patients age 18 or older who received surgery between Jan 1 and Dec 31 for whom both pre-op and 3-month post-op scores are available

MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op score for each for each patient in the population:

M = AVG [post-op – pre-op | patient i]

The average pre-op score is utilized in determining a risk adjustment based on OBERD QCDR data, and the standard deviation of the set of 3-month changes is also computed.

RATIONALE: When patient status is being tracked following a clear protocol, as in OBERD 14, a variety of analyses may be performed on the data. This measure is the most basic such analysis, the average change in raw score of a validated instrument over a (nominal) three month period. This advances the quality agenda in several ways. Most important of these is to help habituate the provider to thinking quantitatively about the efficacy of his or her interventions across his entire practice for the year. A ready target is provided to stimulate the human desire to improve.

OBERD 16: Orthopedic 3-Month Surgery Success Rate

QUALITY DOMAIN: Effective Clinical Care

Type: Outcome:

DESCRIPTION: This measure reports the percentage of all patients showing measurable improvement between pre-op and 3 month post-op score on the basis of a validated PRO instrument for which OBERD QCDR has established a Minimum Detectable Change (MDC) or a Minimum Clinically Important Difference (MCID). Percentages are calculated for both MDC and MCID if both are available for the PRO employed.

DENOMINATOR: Patients 18 or older who have had surgery between Jan 1 and Dec 31 and have a pre-op and a 3-month post-op score available on the basis of a validated PRO instrument for which OBERD QCDR has established a Minimum Detectable Change (MDC) or a Minimum Clinically Important Difference (MCID).

NUMERATOR 1: Patients for whom post-op > pre-op + MDC

NUMERATOR 2: Patients for whom post-op > pre-op + MCID

RATIONALE: Every measuring instrument has a limit to its precision, and this is certainly true of PRO instruments. Nonetheless, many commonly used outcome instruments do not carefully address this point, and in fact are hardly measuring anything in the sense that measurement is understood in the physical sciences. This measure is designed to acquaint providers with this issue by using best practice to answer the most basic treatment question: did patients get better? The first step is that an instrument may not be used unless OBERD QCDR has verified that its precision has been properly determined, usually by reference to the peer-reviewed literature. The MDC is the minimum change that can be regarded as “real”. Although it can be inferred by statistical analysis of collected data, it is not a 95% confidence interval or the like; rather, nothing at all can be inferred about the relative size of two individual measurements that differ by less than the MDC.

A second consideration is whether there is medical significance to the difference even though the difference is objectively real. The scales in most clinics can provide a person’s weight correct to about 0.1 pounds, i.e. MDC is 0.1 lb. But for a particular healthcare purpose, a change in weight might be disregarded if it is less than 5 pounds; the MCID would therefore be 5 lbs. The best instruments are those for which both MCD and MCID are known: the first shows if progress is being made, the second shows if it is enough to be important to patients. This measure reports both if available, but an instrument may be used if either is known.

OBERD 17: CG-CAHPS Patient Rating

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

Type: Outcome

DESCRIPTION: This measure reports the 7 CG-CAHPS composite scores for patients 18 or older who have completed the CG-CAHPS v3 during the measurement period: if completed more than once, the scores are averaged. The scores reflect the percentage of forms on which the provider received the “top box” rating for each composite.

DENOMINATOR: The total number of forms completed during the measurement period by patients 18 or older.

NUMERATOR k: The sum of all scores reported for the k-th composite, k = 1 to 7.

RATIONALE: This measure is designed to promote the use of a standardized patient satisfaction instrument. The composites have been selected by CMS and the CAHPS developers to summarize the results of a 34 question (31 questions if v3 is approved as expected in early 2015) into seven helpful “dimensions.” The scores are easily understood, and national summaries are produced. Regrettably, this analysis is not completed for some nine months or so after the year end, but the preceding year’s scores can provide a close approximation for the use of the provider.

OBERD 18: ORTHOPEDIC 3-MONTH SURGERY OUTCOME WITH PROMIS

QUALITY DOMAIN: Effective Clinical Care

Type: Outcome:

DESCRIPTION: OBERD QCDR includes a completely imbedded Promis CAT system in order to provide these instruments to its participants in a manner identical to all its other web-based data collection facilities. The measures that utilize these instruments have the same structure as any other OBERD QCDR outcome measure, plus the additional benefit of scores referenced to national norms.

PATIENT POPULATION: All patients age 18 or older who received surgery between Jan 1 and Dec 31 for whom both pre-op and 3-month post-op scores are available using the relevant Promis item bank

MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op score for each for each patient in the population:

M = AVG [post-op – pre-op | patient i]

The average pre-op score is utilized in determining a risk adjustment based on the general population. The standard deviation of the set of differences is also reported.

RATIONALE: The Promis Consortium, extensively funded by NIH over several years, is in the process of releasing question banks which address functioning of various joints and musculo-skeletal systems of interest to orthopedists. The Promis approach is distinguished by three features common to all its instruments: it employs computer adaptive testing (CAT) methods to reduce the required number of questions (significantly reducing the burden on patients); its scales are linearized using Item Response Theory (IRT); and it is normed against the U.S. general population and scaled so that the average for the population is 50 and the standard deviation is 10. The Promis scores are broadly applicable, and Promis deserves to be widely known and used where appropriate.

OBERD 19: Orthopedic Surgery 3-Month QoL Changes (VR-6D)

QUALITY DOMAIN: Population and Public Health

Type: Outcome:

DESCRIPTION: This measure calculates the effect of surgery on Quality of Life after 3 months based on the pre-op and post-op values of the VR-6D utility scale.

PATIENT POPULATION: All patients 18 or older for whom a VR-6D score can be calculated both pre-operatively and 3-months post-operatively

MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op VR-6D for each for each patient in the population:

M = AVG [post-op – pre-op | patient i]

The average pre-op score is utilized in determining a risk adjustment based on national data, and the standard deviation of the set of 3-month changes is also computed.

RATIONALE: A utility value (sometimes called patient “preference”) is reported on a 0 to 1 scale, measures quality of life rather than physical or mental function per se, is intended to permit comparisons across medical specialties, and is derived by interviewing a sample of the population using either a “time trade-off” or “standard gamble” methodology. Utility scores are used as a weighting factor to include quality of life in the calculation of the benefit of a medical treatment, as well as the duration of the efficacy of the treatment, by way of the Quality of Life Year (the “Qaly”). The VR-6D has been widely used in CMS studies as well as by the Veterans Administration, which initiated its development. It provides another distinct view to the provider of the quality of care being provided.

OBERD 20: Orthopedic Surgery 3-Month QoL Changes (EQ-5D)

QUALITY DOMAIN: Population and Public Health

Type: Outcome:

DESCRIPTION: This measure calculates the effect of surgery on Quality of Life after 3 months based on the pre-op and post-op values of the EQ-5D utility scale, developed by the EuroQol group, now headquartered in Amsterdam.

PATIENT POPULATION: All patients 18 or older for whom a EQ-5D score can be calculated both pre-operatively and 3-months post-operatively

MEASURE CALCULATION: The measure reported is the average of the difference between pre-op and post-op EQ-5D for each for each patient in the population:

M = AVG [post-op – pre-op | patient i]

The average pre-op score is utilized in determining a risk adjustment based on national data, and the standard deviation of the set of 3-month changes is also computed.

RATIONALE: A utility value is reported on a 0 to 1 scale, measures quality of life rather than physical or mental functon per se, is intended to permit comparisons across medical specialties, and is derived from interviews based on “time trade-off” or “standard gamble” methodologies. Utility scores are used as a weighting factor to include quality of life to the calculation of the benefit of a medical treatment, as well as the duration of the efficacy of the treatment, by way of the Quality of Life Year (the “Qaly”). EQ-5D is widely used in Europe, and its U.S, use is on the rise

OBERD 21: Provider Follow-up of Patient Post-acute Self-care

QUALITY DOMAIN: Communication and Care Coordination

Type: Process

DESCRIPTION: When patients are released to their own care following treatment for an acute condition, there is an increased risk of avoidable adverse events requiring readmission or other additional treatment. This measure tracks preventive follow-up by the provider office.

DENOMINATOR: Number of patients age 18 or older released from clinic, hospital, or other provider care on their own recognizance.

EXCLUSIONS: Any patients receiving care from healthcare professionals (e.g. SNF, HCA, rehab facility, etc.) in the first post-acute week

NQF ID Number: 0

RATIONALE: With the trend toward shortened hospital stays, patients are increasingly released by the provider to his or her own care or that of the person’s family.Even with the use of SNFs, HCA, and in-patient rehab nearly 20% of Medicare hospitalizations are readmissions. Fortunately, there is good evidence that provider contact with the patient at home during the days following release can help detect adverse events early enough to to reduce the patient suffering and the costs that these events entail. Moreover, there is evidence that technology is effective in reducing the burden on the provider.. This measure is intended to encourage patient contact, and especially to emphasize the use of appropriate technology*.

With the trend toward shortened hospital stays, patients are increasingly released by the provider to his or her own care or that of the person’s family.Even with the use of SNFs, HCA, and in-patient rehab nearly 20% of Medicare hospitalizations are readmissions. Fortunately, there is good evidence that provider contact with the patient at home during the days following release can help detect adverse events early enough to to reduce the patient suffering and the costs that these events entail. Moreover, there is evidence that technology is effective in reducing the burden on the provider.. This measure is intended to encourage patient contact, and especially to emphasize the use of appropriate technology.*

Ref: Graham, et al, Med Care 2012;50: 50–57

*( For instance the OBERD QCDR can automate the implementation, tracking and verification of the entire process if electronic communications are used.)