NQF

Measure Applications Partnership
Clinician Workgroup Discussion Guide

In-person meeting dates: December 15-16, 2014
National Quality Forum Conference Center
1030 15th Street NW, 9th Floor, Washington, DC 20005

Meeting Objectives

Agenda

Day 1  


8:45 am   Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach
Mark McClellan, MD, PhD, Workgroup Chair
Reva Winkler, MD, MPH, Senior Director, NQF

9:00 am   Follow-up from October web meeting
Dr. McClellan

9:30 am   Discussion of eMeasures and cost measures
CMS

9:50 am   Overview of Pre-Rulemaking Approach
Dr. Winkler

10:00 am   Consent Calendar 1: Care Coordination
Four process measures are under consideration for PQRS based programs; three are also under consideration for the EHR incentive program (“Meaningful Use”). All measures are still in development. For 2015 PQRS has finalized only two process measures and one outcome measure in the priority area of care coordination.
Lead discussant(s): Rachel Grob, Robert Krughoff
  1. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 4
    • Preliminary analysis summary: Care coordination measure specific for EHRs that uses Clinical Document Architecture (CDA) that specifies how critical data elements should be encoded for exchange and interoperability. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Care coodination measure of ED provider attempting to contact patient's primary care provider or specialist after a patient is seen with with asthma or chest pain. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Care coordination measure of follow-up within 72 hours after an ED visit for asthma or chest pain. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Communication and shared decision-making with patients and families for interventional oncology procedures (MUC ID: X3735)
    • Description: Percentage of patients who have undergone an interventional oncology ablation or catheter-directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was discussed with the patient and/or family member (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Care coordination and patient-centered measure. A patient-reported outcome measure to assess the patient or family's perspective of the discussion would be of higher value than a documentation measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


10:15 am   Consent Calendar 2: Medication Management
Seven process measures are under consideration for PQRS based programs for medication management including four process measures in the new topic area of chronic opioid therpy (COT). Three process measures are under consideration for PQRS based programs (one is also for EHR Incentive) for monitoring warfarin use. For PQRS 2015 there are four process measures for medication management including an intermediate outcome measure for warfarin use.
Lead discussant(s): Amy Mullins, Janis Orlowski
  1. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)

  2. Consideration of Non-Pharmacologic Interventions (MUC ID: X3776)

  3. Documentation of Signed Opioid Treatment Agreement (MUC ID: X3777)

  4. Chronic Opioid Therapy Follow-up Evaluation (MUC ID: X3775)

  5. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Patient safety process eMeasure applied to all patients on warfarin. NQF has endorsed this measure but has not considered the eMeasure. Related to PQRS #380 about the time an atrial fibriallation patient's INR is in the correct range (intermediate outcome). This measure under consideration captures the broadest population of all patients taking warfarin regardless of diagnosis. In view of multiple measures for warfarin management and to promote harmonization and parsimony suggest focusing on a process (monitoring INR) and an intermediate outcome (time in therapeutic range) measure for all patients taking warfarin. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Related to PQRS measure #380 (intermediate outcome) addressing warfarin use in patients with atrial fibrillation. This measure is duplicative and not harmonized with NQF-endorsed measure under consideration E0555 that applies to a broader population of all patients taking warfarin. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  8. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


10:45 am   Consent calendar 3: Emergency care
Three new process measures are under consideration for PQRS programs; two are also for the EHR Incentive program. All measures are still in development. There are only two process measures for emergency care finalized for PQRS 2015. Three of the new measures address appropriate use of imaging and lab tests in the ED.
Lead discussant(s): Beth Averbeck, Mark Metersky
  1. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)

  2. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)

  3. Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding (MUC ID: X3780)

  4. Imaging in adult ED patients with minor head injury (MUC ID: X3764)
    • Description: Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) <=15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Imaging in pediatric ED patients aged 2 through 17 years with minor head injury (MUC ID: X3778)
    • Description: Percent of pediatric patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) of 14 or 15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines (PECARN) prior to imaging (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


11:00 am   Consent calendar 4: Imaging
Six new measures are under consideration for PQRS based programs; all are still in development. Four measures address appropriate use of imaging and one is an adverse outcome measure. For 2015 PQRS has twelve finalized measures for imaging but none in the areas addressed by the new measures.
Lead discussant(s): David Hopkins, Jay Schuur
  1. Appropriate follow-up imaging for incidental abdominal lesions (MUC ID: X3759)

  2. Appropriate follow-up imaging for incidental thyroid nodules in patients (MUC ID: X3763)

  3. Appropriate follow-up imaging for non-traumatic knee pain (MUC ID: X3802)

  4. Appropriate use of imaging for non-traumatic shoulder pain (MUC ID: X3803)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: High-value appropriate use of imaging measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Extravasation of contrast following contrast-enhanced computed tomography (CT) (MUC ID: X3523)

  6. Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy (MUC ID: X3781)

11:15 am   Consent calendar 5: Population Health 1
Lead discussant(s): Diane Padden, Peter Briss
  1. Cervical Cancer Screening (MUC ID: E0032)
    • Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21-64 who had cervical cytology performed every 3 years. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure at the plan and system level.This is a population measure important to consumers is and consistent with the most recent guidelines. Important for dual eligibles. Conditional on successful testing for reliability and validity at the clinician level. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Blood Pressure Screening by age 18 (MUC ID: E1553)
    • Description: The percentage of adolescents who turn 18 years of age in the measurement year who had a blood pressure screening with results. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: "CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented". (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  3. Blood Pressure Screening by age 18 (MUC ID: E1553)

  4. Breast Cancer Screening (MUC ID: X3797)

  5. Unnecessary Screening Colonoscopy in Older Adults (MUC ID: X3769)

  6. Appropriate age for colorectal cancer screening (MUC ID: X3758)

11:30 am   Consent calendar 6: Population Health (children and adolescents)
There is one measure under consideration for the PQRS based programs and three for the EHR Incentive program. For PQRS 2015 there are six population screening measures for children and adolescents but these are new areas.
Lead discussant(s): Terry Adirim, Cynthia Pellegrini
  1. Amblyopia Screening in Children (MUC ID: X3817)

  2. Amblyopia Screening in Children (MUC ID: X3817)

  3. Risky Behavior Assessment or Counseling by Age 13 Years (MUC ID: E1406)
    • Description: The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 13 years. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Suggest broadening the age range and combing this measure with E1507 Risky Behavior Assessment or Counseling by age 18 years. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Risky Behavior Assessment or Counseling by Age 18 Years (MUC ID: E1507)
    • Description: The percentage of children with documentation of a risk assessment or counseling for risky behaviors by 18 years of age. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Suggest broadening the age range and combining with measure E1406 for parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


11:45 am   Consent calendar 7: Population Health 3
There are five new process eMeasures under consideration for the PQRS based programs; four are also under consideration for the EHR Incentive program. All eMeasures are in development. There is only one measure for Hepatitis C screening finalized for PQRS in 2015.
Lead discussant(s): James Pacala, Marci Nielsen
  1. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)
    • Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received a one-time screening for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: A?ligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)

  3. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users (MUC ID: X3513)
    • Description: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Measure is already in PQRS and is a high priority quality issue for dual eligibles. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)

  5. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)
    • Description: Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. HIV: Ever screened for HIV (MUC ID: X3299)

  7. HIV: Ever screened for HIV (MUC ID: X3299)

  8. HIV Screening of STI patients (MUC ID: X3300)

  9. HIV Screening of STI patients (MUC ID: X3300)

12:00 pm   Consent calendar 8: Population Health 4
Three eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program including one composite measure; all are in development. There is one measure for alcohol use screening finalized for PQRS 2015.
Lead discussant(s): Amy Mullins, Luther Clark
  1. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)

  2. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)

  3. Substance Use Screening and Intervention Composite (MUC ID: X3475)

  4. Substance Use Screening and Intervention Composite (MUC ID: X3475)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 7
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 6
    • Preliminary analysis summary: An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009. This measure is also duplicative of composite MUC X3475 as alcohol screening is one of the components. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  6. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 3
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


1:00 pm   Consent calendar 9: Mental Health and Substance Use
Three eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program; all are in development. The new measures include an outcome measure and a medication safety measure. There are no measures in these areas finalized for PQRS in 2015.
Lead discussant(s): Amy Moyer, Amy Compton-Phillips
  1. ADHD: Symptom Reduction in Follow-up Period (MUC ID: X3280)

  2. ADHD: Symptom Reduction in Follow-up Period (MUC ID: X3280)
    • Description: Percentage of children aged 4 through 18 years, with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), who demonstrated a 25% reduction in symptoms 6-12 months from baseline as measured using the Vanderbilt ADHD Diagnostic Rating Scale, regardless of treatment prescribed. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (MUC ID: X3472)

  4. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (MUC ID: X3472)

  5. Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting (MUC ID: X4007)
    • Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current alcohol dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period (MUC ID: X4208)
    • Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial and pharmacologic treatment options for opioid addiction within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Overlap with PQRS measure #305 (NQF #0004) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). This measure under consideration addresses all patients with current opioid dependence compared to measure #305 that addresses new onset episode of alcohol and drug dependency. Harmonization and consolidation of all substance use measures is indicated to promote parsimony. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


1:15 pm   Consent calendar 10: Cardiovascular conditions
There are five measures under consideration for the PQRS based programs, one is also for the EHR Incentive program. One composite measure is an updated measure previously finalized for PQRS with new specifications reflecting the latest guidelines. In 2015 PQRS has finalized fifteen measures for cardiovascular care addressing coronary artery disease, heart failure, hypertension and stroke.
Lead discussant(s): James Pacala, Diane Padden
  1. Optimal Vascular Care (MUC ID: E0076)
    • Description: Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use[For reference, description of endorsed measure from QPS: Percentage of adult patients ages 18 to 75 who have ischemic vascular disease with optimally managed modifiable risk factors (blood pressure, tobacco-free status, daily aspirin use).] (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Revised composite outcome measure (removed the lipid component due to new guidelines) to replace the prior version finalized in PQRS. Conditional on the revised measure being submitted for NQF endorsement. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 2
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: The measure conforms to new guidelines for statin use and should replace prior measures based on old guidelines. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Controlling High Blood Pressure (MUC ID: X3792)
    • Description: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on testing for reliability and validity at the clinician-level and review by NQF pending final hypertension guidelines from ACC due in 2015. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  5. Clinical Outcome post Endovascular Stroke Treatment (MUC ID: X3756)

  6. Door to puncture time for endovascular stroke treatment (MUC ID: X3747)

1:30 pm   Consent calendar 11: Asthma
The only asthma measure under consideration is a new composite measure containing two outcome components. The finalized PQRS measures include two process measures and one outcome measure that is included in the new composite.
Lead discussant(s): Marci Nielsen, Janis Orlowski
  1. Optimal Asthma Care 2014 (MUC ID: X3773)

  2. Optimal Asthma Care 2014 (MUC ID: X3773)

1:40 pm   Consent calendar 12: Diabetes and Renal
The measures under consideration include one new eMeasure for diabetes for PQRS based programs and the EHR Incentive program. Two measures for renal disease are under consideration for PQRS based programs. Diabetes and renal disease are conditions with numerous measures already finalized for PQRS 2015.
Lead discussant(s): Marci Nielsen, Janis ORlowski
  1. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)

  2. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)

  3. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)

  4. Pediatric Kidney Disease: Discussion of Care Planning (MUC ID: X3733)

1:50 pm   Consent calendar 13: Cognitive impairment/Dementia
Two new eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program. There are nine measures for dementia finalized for PQRS 2015.
Lead discussant(s): Constance Dahlin, Rachel Grob
  1. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)

  2. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)
    • Description: The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: The Medicare Annual Wellness Visit specifies "detection of any cognitive impairment". Although the USPSTF stated that the evidence is insufficient to recommend screening for cognitive impairment in asymptomatic population though age 80 years and above were not specifically addressed. Important for dual eligibles. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: See PQRS measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


2:00 pm   Consent calendar 14: Gastrointestinal conditions
There are two measures under consideration for the PQRS based programs and an episode based cost measure for the Value Based Payment Modifer (VBPM). There are six measures finalized for PQRS 2015 addressing aspects of colonoscopy performance and inflammatory bowel disease.
Lead discussant(s): Amy Mullins, Luther Clark
  1. Frequency of inadequate bowel preparation (MUC ID: X3760)

  2. Photodocumentation of cecal intubation (MUC ID: X3761)

  3. Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure (MUC ID: X0355)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Cost measures are required for VBPM. Quality measures are needed for GI hemorrhage to match with the cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


2:15 pm   Consent calendar 15: Perinatal
There are two similar outcome measures under consideration for the PQRS based programs. For 2015 there are four process measures and one outcome measures in this topic area finalized for PQRS.
Lead discussant(s): Cynthia Pellegrini, Terry Adirim
  1. Primary C-Section Rate 2014 (MUC ID: X3768)

  2. PC-02 Cesarean Section (Provider Level) (MUC ID: X3788)
    • Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is 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). (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Duplicative of measure under consideration X3768 that is already in use in private programs. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


2:25 pm   Consent calendar 16: Musculoskeletal conditions
There are three eMeasures under consideration for both PQRS based programs and the EHR Incentive program. Two measures in the new topic area of gout were recently evaluated by NQF for approval as “eMeasures for Trial Use”. In the musculoskeletal topic area, there are 22 measure finalized for PQRS in 2015 in the areas of functional status, rheumatoid arthritis, osteoporosis and osteoarthritis.
Lead discussant(s): David Seidenwurm, Mark Metersky
  1. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Support development as a functional patient-reported outcome eMeasure, not just  "score from one of a select list of pain interference assessment tools was recorded at least twice".  A PRO of improvement in pain associated with osteoarthritis fills a needed gap in PROs and functional status measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: See PQRS eMeasure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: This is the first measure for gout - a condition affecting more than 8 million Americans and affects African Americn men three times more than white men. Important for dual eligibles. NQF-approved eMeasure for Trial Use. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: NQF approved this eMeasure for Trial Use in 2014. Aligns wirth PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Gout: Serum Urate Monitoring (MUC ID: S2521)

  6. Gout: Serum Urate Monitoring (MUC ID: S2521)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 0
    • Preliminary analysis summary: NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


3:00 pm   Consent calendar 17: Neurology - headaches
Eleven measures are under consideration for the PQRS based programs for headaches including primary headache disorders, cluster headaches and migraines. This is a new topic area for PQRS.
Lead discussant(s): Jay Schuur, David Seidenwurm
  1. Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination (MUC ID: X3785)

  2. Quality Of Life Assessment For Patients With Primary Headache Disorders (MUC ID: X3786)

  3. Migraine Or Cervicogenic Headache Related Disability Functional Status (MUC ID: X3796)
    • Description: Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: This process measure documents functional status assessment. A better measure would determine whether the disability functional status score remained the same or improved during a recent timeframe simiar to MUC X3786 for Quality of Life. Conditional on testing at the clincian-level and submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  4. Overuse of Barbiturate Containing Medications for Primary Headache Disorders (MUC ID: X3765)

  5. MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK (MUC ID: X3771)

  6. Preventive Migraine Medication Prescribed (MUC ID: X3772)
    • Description: Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is >= 4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Measure of appropriate preventive treatment for patients with frequent migraines. Conditional on testing at the clincian-level and submission for NQF endorsement. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (MUC ID: X3766)

  8. Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders (MUC ID: X3783)

  9. Plan Of Care Or Referral For Possible Medication Overuse Headache (MUC ID: X3784)

  10. Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed (MUC ID: X3794)

  11. Overuse Of Opioid Containing Medications For Primary Headache Disorders (MUC ID: X3770)

3:30 pm   Consent calendar 18: Neurology - muscular dystrophy
Six new measures are under consideration for PQRS based programs in the new topic area of muscular dystrophy.
Lead discussant(s): Amy Mullins, Robert Krughoff
  1. Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy (MUC ID: X3787)
    • Description: All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Muscular dystrophy is a group of nine inherited diseases of progressive muiscle weakness affecting more than 50,000 Americans. This process measure in new condition area measures use of evidence-based therapy that can slow the progression of the disease. Conditional on satisfactory testing at the clincian-level and submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Patient Queried about Pain and Pain Interference with Function (MUC ID: X3800)

  3. Patient Counseled About Health Care Decision-Making (MUC ID: X3789)

  4. Scoliosis Evaluation Ordered (MUC ID: X3798)

  5. Nutritional Status or Growth Trajectories Monitored (MUC ID: X3801)

  6. MD Multidisciplinary Care Plan Developed or Updated (MUC ID: X3791)

3:45 pm   Consent calendar 19: Skin conditions
Two measures for PQRS in the new topic area of psoriasis including one outcome measure. There is also an episode based cost measure for cellulitis in development for the VBPM.
Lead discussant(s): Marci Nielsen, Amy Moyer
  1. Clinical Response to Oral Systemic or Biologic Medications (MUC ID: X3726)
    • Description: This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Outcome measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement.  (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Assessment for Psoriatic Arthritis (MUC ID: X3274)

  3. Cellulitis Clinical Episode-Based Payment Measure (MUC ID: X0354)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Quality measures are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


3:55 pm   Consent calendar 20: Surgery - peri-operative and anesthesia
Six measures are under consideration for PQRS based programs. All are in development. There are very few measures finalized for PQRS 2015 in this topic area.
Lead discussant(s): Peter Briss, Bruce Sherman
  1. Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents (MUC ID: X3808)

  2. Anesthesiology Smoking Abstinence (MUC ID: X3811)

  3. Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination (MUC ID: X3806)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: This process measure includes evaluation of risk for PONV and adminstration of appropriate preventive medications. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Perioperative Temperature Management (MUC ID: X3809)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Intermediate outcome measure revised from a prior process measure. Additional measure for anesthesia. Recommend clarification of the specifications as discussed with the NQF Surgery Standing Committee in May 2014 as the measure is further developed and tested. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  5. Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) (MUC ID: X3807)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for reliability and valdity and meaningful differences among anesthesia providers will be important. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) (MUC ID: X3810)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for realiability and valdiity and meaningful differences among anesthesia providers will be important. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


4:05 pm   Consent calendar 21: Surgery - orthopedics
Two patient-reported outcome eMeasures are under consideration for both the PQRS based programs and the EHR Incentive program. Additionally three episode based payment measures are under consideration for the VBPM.
Lead discussant(s): Eric Whitaker, Rachel Grob
  1. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)

  2. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)
    • Description: Average change in functional status assessment score for 19 years and older with primary total knee arthroplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)
    • Description: Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare and Medicaid EHR Incentive Programs
    • Public comments received: 1
    • Preliminary analysis summary: Aligns with PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)

  5. Knee Replacement/ Revision Clinical Episode-Based Payment Measure (MUC ID: X0352)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 2
    • Preliminary analysis summary: Can be matched with 3 finalized measures for knee replacement in PQRS. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  6. Hip Replacement/ Revision Clinical Episode-Based Payment Measure (MUC ID: X0356)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 3
    • Preliminary analysis summary: Though surgery measures are finalized in PQRS, additional quality measures specific to hip replacedment are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. Spine Fusion/ Refusion Clinical Episode-Based Payment Measure (MUC ID: X0353)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 1
    • Preliminary analysis summary: Quality measure are needed for spine surgery to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


4:20 pm   Consent calendar 22: Surgery - vascular
Two measures are under consideration for the PQRS based programs including a mortality outcome measure.
Lead discussant(s): David Hopkins, Mark Metersky
  1. In-hospital mortality following elective open repair of AAAs (MUC ID: E1523)

  2. Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy (MUC ID: E0465)
    • 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] (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure. Evidence-based process measure that promotes secondary prevention of vasular disease beyond the timeframe of surgery. Complements two outcome measures for this procedure. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


4:30 pm   Consent calendar 23: Interventional radiology
Three measures for interventional radiology are under consideration for PQRS based programs including two outcome measures. All are in development.
Lead discussant(s): David Seidenwurm, Bruce Sherman
  1. Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment (MUC ID: X3739)

  2. Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal (MUC ID: X3755)

  3. Rate of surgical conversion from lower extremity endovascular revascularization procedure (MUC ID: X3754)

4:40 pm   Consent calendar 24: Genitourinary conditions
Eleven measures are under consideration for the PQRS based programs in the new topic area of pelvic prolapse surgery. Of these, three are adverse outcome measures. There is only one GU measure finalized for PQRS in 2015. An episode based payment measure for the VBPM is also under consideration.
Lead discussant(s): Beth Averbeck, Eric Whitaker
  1. Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury (MUC ID: X3752)

  2. Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair (MUC ID: X3743)

  3. Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair (MUC ID: X3813)

  4. Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair (MUC ID: X3744)

  5. Performing an intraoperative rectal examination at the time of prolapse repair (MUC ID: X3740)

  6. Preoperative assessment of sexual function prior to any pelvic organ prolapse repair (MUC ID: X3742)

  7. Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair (MUC ID: X3746)

  8. Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair (MUC ID: X3741)

  9. Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair (MUC ID: X3751)
    • Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP-Q or Baden/Walker) (Full Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 0
    • Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  10. Preoperative pessary for pelvic organ prolapse offered (MUC ID: X3750)

  11. Preoperative pessary for pelvic organ prolapse attempted (MUC ID: X3745)

  12. Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (MUC ID: X0351)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Physician Feedback; Value-Based Payment Modifier
    • Public comments received: 4
    • Preliminary analysis summary: Quality measures are needed to match this cost measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


5:00 pm    Adjourn


Day 2  


8:30 am   MAP Feedback on 2015 Physician Fee Schedule Final Rule
Kate Goodrich, MD, CMS

9:15 am   Consent calendar 25: MSSP - Support
Three NQF-endorsed measures under consideration for MSSP.
Lead discussant(s): Amy Moyer, Amy Mullins
  1. Breast Cancer Screening (MUC ID: X3797)
    • Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the past 27 months. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


  2. Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy [Measure referred from hospital workgroup] (MUC ID: E0465)
    • 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] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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.  (Full Preliminary Analysis)
    • Preliminary analysis result: Support


  3. In-hospital mortality following elective open repair of AAAs [Measure referred from hospital workgroup] (MUC ID: E1523)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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. (Full Preliminary Analysis)
    • Preliminary analysis result: Support


9:45 am   Consent calendar 26: MSSP - Conditional Support
Eighteen measures under consideration are conditionally supported for the MSSP. These measures should be submitted to NQF for review and endorsement.
Lead discussant(s): Janis Orlowski, Rachel Grob
  1. Prevention Quality Indicators #90 (PQI #90) (MUC ID: X3715)
    • Description: Prevention Quality Indicators (PQI) overall composite per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Requires testing at ACO level. Need to consider appropriateness of conditions within composite for Medicare FFS population. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  2. Optimal Asthma Care 2014 (MUC ID: X3773)
    • Description: Composite (“optimal” care) measure of the percentage of pediatric and adult patients who have asthma and meet specified targets to control their asthma. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important composite measure with patient-reported outcome measure component measure. Updated measure will be submitted to NQF for endorsement review. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  3. Optimal Vascular Care (MUC ID: E0076)
    • Description: Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use[For reference, description of endorsed measure from QPS: Percentage of adult patients ages 18 to 75 who have ischemic vascular disease with optimally managed modifiable risk factors (blood pressure, tobacco-free status, daily aspirin use).] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Composite outcome measure for highly prevalent condition important to Medicare patients. Conditonal on successful maintenace review of revised measure by NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  4. Coronary Artery Disease (CAD): Symptom Management: (MUC ID: X1033)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measure assesses patient-reported activity and management. Conditional support pending submission to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  5. Depression Utilization of the PHQ-9 Tool (MUC ID: E0712)
    • Description: Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD-9 296.2x, 296.3x or 300.4) who have a PHQ-9 tool administered at least once during the four month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: NQF-endorsed measure intended to be paired with one of two outcome measures - Depression Remission at 6 month and Depresion Remission at 12 months; condiitonal on pairing with either or both outcome measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  6. Depression Remission at Six Months (MUC ID: E0711)
    • Description: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (± 30 days) PHQ-9 score of less than five. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Support a depression outcome measure for MSSP. Should align with other federal programs. PQRS measure focused on 12 month remission. Recommend pairing with measure 0712 Use of PHQ9. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  7. Controlling High Blood Pressure (MUC ID: X3792)
    • Description: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on review by NQF pending final hypertension guidelines from ACC due in 2015. Existing BP control measure already in MSSP program. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  8. Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination (MUC ID: X3785)
    • Description: Percentage of patients with a diagnosis of primary headache disorder with a normal neurological examination* for whom advanced brain imaging (CTA, CT, MRA or MRI) was NOT ordered. [NQF edit] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Conditional on measure testing and submission to NQF for endorsement. Multiple headache measures may be appropriate for a MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  9. Quality Of Life Assessment For Patients With Primary Headache Disorders (MUC ID: X3786)
    • Description: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important PROM appropriate for clinician level measurement; may be too narrow for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  10. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support.


  11. Documentation of Signed Opioid Treatment Agreement (MUC ID: X3777)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  12. Consideration of Non-Pharmacologic Interventions (MUC ID: X3776)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration with whom the clinician discussed non-pharmacologic interventions (e.g. graded exercise, cognitive/behavioral therapy, activity coaching at least once during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to alternatives to chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  13. Chronic Opioid Therapy Follow-up Evaluation (MUC ID: X3775)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during COT documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  14. TOTAL PER CAPITA COST MEASURE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES (MUC ID: X2147)
    • Description: The ratio of all actual Medicare FFS Parts A and B payments to a medical group practice for beneficiaries attributed to it over a calendar year to all expected payments to the medical group practice, multiplied by the payment for the average beneficiary in the sample. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Meet MSSP programmatic objectives. Support pending submission of revised measure to NQF. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  15. Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3743)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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 (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  16. Proportion of patients sustaining a major viscus injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3744)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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. (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  17. Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3813)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary:   Conditional Support pending NQF review and endorsement (Full Preliminary Analysis)
    • Preliminary analysis result: Conditional support


  18. Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury [Measure referred from hospital workgroup] (MUC ID: X3752)

   Consent calendar 27: MSSP - Encourage further development
Of 56 measure under consideration that are still in development, 38 are recommended for continued development for potential use in MSSP.
Lead discussant(s): Mark Metersky, David Hopkins
  1. Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure (MUC ID: X3481)
    • Description: Percentage of patients aged 65 years and older with congestive heart failure who had a target improvement goal defined after completing an initial patient-reported functional status assessment and met the goal after completing a follow-up functional status assessment (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures such as patient-reported outcomes in the area of functional status measures. However, this measure needs further development and testing to be ready for implementation. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  2. Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements (MUC ID: X3483)
    • Description: Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  3. Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements (MUC ID: X3482)
    • Description: Average change in functional status assessment score for 19 years and older with primary total knee arthroplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  4. Clinical Outcome post Endovascular Stroke Treatment (MUC ID: X3756)
    • Description: Patients with 90 day mRs score of 0 to 2 post endovascular stroke intervention (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important patient-function measure after stroke treatment. Ideally, broader patient population would be preferable for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage further development


  5. Extravasation of contrast following contrast-enhanced computed tomography (CT) (MUC ID: X3523)
    • Description: Percentage of final reports for patients aged 18 years and older who received intravenous iodinated contrast for a computed tomography (CT) examination who had an extravasation of contrast Lower performance rate is the goal. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important adverse event for hospital setting; may not add value for ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  6. Appropriate age for colorectal cancer screening (MUC ID: X3758)
    • Description: Percentage of average-risk patients age 86 or older who underwent screening colonoscopy (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary: Important area of potential overuse in Medicare population. Need to consider harmonization/selection among competing measures colonoscopy overuse measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  7. Unnecessary Screening Colonoscopy in Older Adults (MUC ID: X3769)
    • Description: Percentage of patients age 86 or older who received an unnecessary screening colonoscopy. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important overuse measure for common screening test. Need to reconcile across competing colonoscopy overuse measure (including X3758). (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  8. Appropriate follow-up imaging for non-traumatic knee pain (MUC ID: X3802)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic knee pain who undergo knee magnetic resonance imaging (MRI) or magnetic resonance arthrography (MRA) who are known to have had knee radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  9. Appropriate use of imaging for non-traumatic shoulder pain (MUC ID: X3803)
    • Description: Percentage of imaging studies for patients aged 18 years and older with non-traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  10. Communication and shared decision-making with patients and families for interventional oncology procedures (MUC ID: X3735)
    • Description: Percentage of patients who have undergone an interventional oncology ablation or catheter-directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was discussed with the patient and/or family member (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Reflects shared decisionmaking for medically complex patients. Optimally would include patient voice. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  11. Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding (MUC ID: X3780)

  12. Frequency of inadequate bowel preparation (MUC ID: X3760)
    • Description: The percentage of outpatient examinations with “inadequate” bowel preparation that require repeat colonoscopy in one year or less (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 3
    • Preliminary analysis summary: Important measure regarding colonoscopy preparation. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  13. Closing the Referral Loop - Critical Information Communicated with Request for Referral (MUC ID: X3283)
    • Description: Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA-based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Care coordination is a priority for Medicare patients and a good assement of an ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  14. Closing the Referral Loop - Specialist Report Sent to Primary Care Physician (MUC ID: X3302)
    • Description: Percentage of referrals received for which the receiving provider sent a consultant report back to the referring provider. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Care coordination across providers is a critical program objective. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  15. Coordinating Care - Emergency Department Referrals (MUC ID: X3466)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions. Encourage harmonization with PCPI regarding transition record measure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  16. Coordinating Care - Follow-Up with Eligible Provider (MUC ID: X3465)
    • Description: Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  17. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (MUC ID: X3729)
    • Description: Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with any fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >=190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: High priority area. Meets program objective for risk assessment and intervention. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  18. Cognitive Impairment Assessment Among At-Risk Older Adults (MUC ID: X3469)
    • Description: Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Dementia is a high priority area for Medicare. Results of cognitive assessment will be captured in EHR. Need to consider insufficient rating from USPSTF due to lack of evidence that early screening or intervention improves outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  19. Documentation of a Health Care Proxy for Patients with Cognitive Impairment (MUC ID: X3468)
    • Description: The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Healthcare proxy requires coordination across providers. High priority area for Medicare and MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  20. Comprehensive Diabetes Care: Eye Exam (MUC ID: E0055)
    • Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who received a retinal or dilated eye exam during the measurement year or a negative retinal or dilated eye exam in the year prior to the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure for diabetes; requires coordination to ensure care delivery and documentation. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  21. Diabetes: Hemoglobin A1c Overtreatment in the Elderly (MUC ID: X3476)
    • Description: Percentage of patients 65 years of age and older with diabetes who had hemoglobin A1c < 7.0% during the measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Submission to NQF for review. Age cut-off at 65 years needs further review (highly dependent on functional status and related co-morbidities) (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  22. Alcohol Screening and Brief Intervention (ASBI) in the ER (MUC ID: X3445)
    • Description: Percentage of patients aged 15 to 34 seen in the ER for injury who were screened for hazardous alcohol use AND provided a brief intervention within 7 days of the ER visit if screened positive. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  23. Imaging in adult ED patients with minor head injury (MUC ID: X3764)
    • Description: Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) <=15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important measure of appropriateness for MSSP. Need to consider competing measures related to ED imaging (NQF#0668). (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  24. Photodocumentation of cecal intubation (MUC ID: X3761)
    • Description: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary: Important measure regarding colonoscopy adequacy. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  25. Appropriate follow-up imaging for incidental abdominal lesions (MUC ID: X3759)
    • Description: Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: - liver lesion < 1.5 cm - kidney lesion < 1.0 cm - adrenal lesion < 4.0 cm Lower performance rate is goal (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: High value measure of potential imaging overuse. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  26. Appropriate follow-up imaging for incidental thyroid nodules in patients (MUC ID: X3763)
    • Description: Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended Lower performance rate is goal. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measure related to imaging overuse. It may be somewhat narrow for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  27. Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin (MUC ID: X3485)
    • Description: Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Multiple measures related to INR monitoring for certain conditions (e.g., atrial fibrillation). Measures should be harmonized with preference for outcome, including time in therapeutic range. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  28. INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) (MUC ID: E0555)
    • Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Appropriate for MSSP program. Requires coordination of care across providers. If possible, should incorporate outcome for time in therapeutic range. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  29. Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis (MUC ID: X3053)
    • Description: Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Meets program objectives. Could be appropriate PROM for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  30. Gout: Urate Lowering Therapy (MUC ID: S2550)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT) (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician measure in gap area. New eMeasure to be tested. Not appropriate for MSSP program. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  31. Intimate Partner (Domestic) Violence Screening (MUC ID: X3446)
    • Description: Percentage of female patients aged 15-40 years old who were screened for intimate partner (domestic) violence at any time during the reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  32. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (MUC ID: E2152)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Population screening for alcohol dependence; support development for PRS and EHR Incentive also. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  33. Substance Use Screening and Intervention Composite (MUC ID: X3475)
    • Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 4
    • Preliminary analysis summary: Important area of focus; new eMeasure. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  34. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Supports appropriate referral to hospice. Reflects coordination and collaboration across ACO. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  35. Door to puncture time for endovascular stroke treatment [Measure referred from hospital workgroup] (MUC ID: X3747)
    • Description: Door to puncture time less than 2 hours for patients undergoing endovascular stroke treatment (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • 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. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  36. Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination [Measure referred from hospital workgroup] (MUC ID: X3806)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: This measure addresses an important area for potential surgical care improvement for Medicare beneficiaries. (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  37. Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) [Measure referred from hospital workgroup] (MUC ID: X3807)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • 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.  (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


  38. Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) [Measure referred from hospital workgroup] (MUC ID: X3810)
    • 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. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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.  (Full Preliminary Analysis)
    • Preliminary analysis result: Encourage continued development


10:30 am   Consent calendar 28: MSSP -Do not support
Thirty fully developed measures are not supported for MSSP. Some do not apply to the Medicare population and others address very narrow conditions or patient populations.
Lead discussant(s): Davis Seidenwurm, Robert Krughoff
  1. Coronary Artery Disease (CAD): Antiplatelet Therapy (MUC ID: E0067)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Optimal Vascular Care measure (E0076) contains this measure as a component of the composite. Both measures would be redundant. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  2. Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) (MUC ID: E0070)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy There are two reporting criteria for this measure: (1) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% OR (2) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have prior myocardial infarction"[For reference, descriptin of endorsed measure from QPS: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy] (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinical measure that does not reflect MSSP program objectives. Beta blocker persistence ( NQF #71) measure may better reflect care across continuum. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  3. Overuse of Barbiturate Containing Medications for Primary Headache Disorders (MUC ID: X3765)
    • Description: Percentage of patients age 18 years old and older with a diagnosis of primary headache who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  4. ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE (MUC ID: X3766)
    • Description: Percentage of patients age 18 years old and older with a diagnosis of cluster headache (CH) who were prescribed a guideline recommended acute medication for cluster headache within the 12-month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  5. Overuse Of Opioid Containing Medications For Primary Headache Disorders (MUC ID: X3770)
    • Description: Percentage of patients aged 12 years and older diagnosed with primary headache disorder and taking opioid containing medication who were assessed for opioid containing medication overuse within the 12-month measurement period and treated or referred for treatment if identified as overusing opioid containing medication. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  6. MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK (MUC ID: X3771)
    • Description: Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  7. Preventive Migraine Medication Prescribed (MUC ID: X3772)
    • Description: Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is >= 4 migraine attacks per month or migraine frequency was >= 8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  8. Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders (MUC ID: X3783)
    • Description: Percentage of patients diagnosed with a primary headache disorder, who are actively taking an acute headache medication and experiencing headaches >= 15 days per month for 3 months, who were assessed for medication overuse headache (MOH). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  9. Plan Of Care Or Referral For Possible Medication Overuse Headache (MUC ID: X3784)
    • Description: Percentage of patients diagnosed with medication overuse headache (MOH) within the past 3 months or who screened positive for possible MOH (measure 6a) who had a medication overuse plan of care created or who were referred for this purpose. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  10. Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed (MUC ID: X3794)
    • Description: All patients diagnosed with migraine headache or cervicogenic headache who had a headache management plan of care developed or reviewed at least once during the 12 month measurement period. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  11. Migraine Or Cervicogenic Headache Related Disability Functional Status (MUC ID: X3796)
    • Description: Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  12. Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair (MUC ID: X3741)
    • Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  13. Preoperative assessment of sexual function prior to any pelvic organ prolapse repair (MUC ID: X3742)
    • Description: Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  14. Preoperative pessary for pelvic organ prolapse attempted (MUC ID: X3745)
    • Description: The percentage of patients who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  15. Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair (MUC ID: X3746)
    • Description: Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure addresses a gap in speciality measurement. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  16. Preoperative pessary for pelvic organ prolapse offered (MUC ID: X3750)
    • Description: The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not relate to MSSP program objectives. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  17. Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair (MUC ID: X3751)
    • Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP-Q or Baden/Walker) (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  18. Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy (MUC ID: X3787)
    • Description: All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  19. Patient Counseled About Health Care Decision-Making (MUC ID: X3789)
    • Description: All patients with a diagnosis of a muscular dystrophy (MD), or their caregivers who were counseled about advanced health care decision making, palliative care, or end-of-life issues at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  20. MD Multidisciplinary Care Plan Developed or Updated (MUC ID: X3791)
    • Description: All patients diagnosed with a muscular dystrophy (MD) for whom a MD multi-disciplinary care plan was developed, if not done previously, or the plan was updated at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  21. Scoliosis Evaluation Ordered (MUC ID: X3798)
    • Description: All visits for patients with a diagnosis of a muscular dystrophy (MD) where the patient had a scoliosis evaluation ordered. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  22. Patient Queried about Pain and Pain Interference with Function (MUC ID: X3800)
    • Description: All visits for patients diagnosed with a muscular dystrophy (MD) where the patient was queried about pain and pain interference with function using a validated and reliable instrument. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  23. Nutritional Status or Growth Trajectories Monitored (MUC ID: X3801)
    • Description: All visits for patients diagnosed with muscular dystrophy (MD) where the patient’s nutritional status or growth trajectories were monitored. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support for MSSP


  24. Primary C-Section Rate 2014 (MUC ID: X3768)

  25. PC-02 Cesarean Section (Provider Level) (MUC ID: X3788)
    • Description: This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is 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). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Important measure. Not appropriate for Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  26. Cervical Cancer Screening (MUC ID: E0032)
    • Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21-64 who had cervical cytology performed every 3 years. 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: A good measure for ACOs in general, but not applicable to the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  27. Assessment for Psoriatic Arthritis (MUC ID: X3274)
    • Description: This measure evaluates the number of all psoriasis patients who are screened for psoriatic arthritis. Doing this helps to prevent structural damage, and maximizes quality of life (QOL). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Narrow topic area - better for clinicians/specialists. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  28. Clinical Response to Oral Systemic or Biologic Medications (MUC ID: X3726)
    • Description: This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  29. ALS Multidisciplinary Care Plan Developed or Updated (MUC ID: X2809)
    • Description: Percentage of patients diagnosed with ALS for whom a multi-disciplinary care plan was developed, if not done previously, and the plan was updated at least once annually. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure captures very few Medicare patients. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


  30. Performing an intraoperative rectal examination at the time of prolapse repair [Measure referred from hospital workgroup] (MUC ID: X3740)
    • Description: Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior prolapse. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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.  (Full Preliminary Analysis)
    • Preliminary analysis result: Do not support


11:00 am   Consent calendar 29: MSSP -Do not encourage further consideration
Eighteen measures in development are not recommended for further consideration for MSSP.
Lead discussant(s): Jay Schuur, James Pacala
  1. Diabetes: Foot exam (MUC ID: E0056)
    • Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Diabetes process measure that does not reflect care across continuum or coordination of services. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  2. Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection (MUC ID: X3816)
    • Description: Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Health risk screening with follow-up. Could possibly be combined with isolated screening measure (x3512). Most appropriate for duals population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  3. HIV medical visit frequency (MUC ID: E2079)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression) (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  4. HIV Viral Load Suppression (MUC ID: E2082)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. This intermediate outcome measure preferred to HIV process measures. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  5. Prescription of HIV Antiretroviral Therapy (MUC ID: E2083)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression) (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  6. Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy (MUC ID: X3781)
    • Description: Percentage of final reports for patients aged 18 years and older who had a previously documented contrast reaction who undergo any imaging examination using intravenous iodinated contrast that include documentation that the patients were pre-medicated with corticosteroids with or without H1 antihistamines (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  7. Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment (MUC ID: X3739)
    • Description: Percentage of patients treated for varicose veins (CEAP C2) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that receive a disease specific patient reported outcome survey before and after treatment. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. Preference for PROM with patient results. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  8. Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal (MUC ID: X3755)
    • Description: Proportion of patients in whom a retrievable IVC filter is placed who, within 3 months post- placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  9. Gout: Serum Urate Monitoring (MUC ID: S2521)
    • Description: Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: NQF did not approve this eMeasure for trial Use due to lack of evidence of relationship to patient outcomes. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  10. Use of Imaging Studies for Low Back Pain (MUC ID: E0052)
    • Description: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur). (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Measures applies to ages 18-50 years. Not applicable to the Medicare population. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  11. HIV Screening of STI patients (MUC ID: X3300)

  12. HIV: Ever screened for HIV (MUC ID: X3299)

  13. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users (MUC ID: X3513)
    • Description: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  14. Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (MUC ID: X3512)
    • Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received a one-time screening for HCV infection (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  15. Rate of surgical conversion from lower extremity endovascular revascularization procedure (MUC ID: X3754)
    • Description: In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration for MSSP


  16. Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents [Measure referred from hospital workgroup] (MUC ID: X3808)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • 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. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  17. Perioperative Temperature Management [Measure referred from hospital workgroup] (MUC ID: X3809)
    • 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 (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • Preliminary analysis summary: This measure has been retired by the measure steward, CMS. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


  18. Anesthesiology Smoking Abstinence [Measure referred from hospital workgroup] (MUC ID: X3811)
    • Description: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure. (Full Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 0
    • 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. (Full Preliminary Analysis)
    • Preliminary analysis result: Do not encourage further consideration


11:45 am   Discussion of gaps in the Clinician Quality Programs


12:45 pm   Discussion of Programmatic Deliverable


2:00 pm   Adjourn



Appendix A: Preliminary Analysis

Preliminary Analysis Index


Full Preliminary Analysis

ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3766)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Cluster headaches are underdiagnosed and undertreated. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS strategy for promoting the most effective prevention and treatment practices

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: CH is under diagnosed and undertreated. Although CH has a much lower prevalence than many other types of headache, it is often considered the most severe headache pain. Suicidality ideations in one study were as high as 55% of the study population.


ACUTE MEDICATION PRESCRIBED FOR CLUSTER HEADACHE for program(s): MSSP (MUC ID: X3766)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: CH is under diagnosed and undertreated. Although CH has a much lower prevalence than many other types of headache, it is often considered the most severe headache pain. Suicidality ideations in one study were as high as 55% of the study population.


ADHD: Symptom Reduction in Follow-up Period for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3280)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Hight-value, patient reported outcome measure. 

Does the measure address a critical program objective as defined by MAP? Yes. This patient reported outcome is a high value measure that fills a noted gap in pediatric behavioral health measurement.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? No. Measure currently being tested.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

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.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: According to the CDC, approximately 9% of children age 4-17 have ADHD and the rate of ADHD diagnosis has increased an average of 5% per year from 2003 to 2007. Evidence exists that shows there is a lack of a standard approach to ADHD diagnosis and adherence to treatment guidelines. One likely cause of the poor provision of ADHD care is the logistical issue surrounding collection of ADHD rating scales from parents and teachers. Collection of rating scales requires knowledge of appropriate ratings scales to use, time to explain the purpose of collecting rating scales to parents, distribution of rating scales to and from home, coordination of distributing and collecting rating scales from school, scoring of completed ratings, and, finally, interpretation of results. This comprises a complex data management process that typically goes un- or under-reimbursed in pediatric settings. Without the collection of these results, the quality of ADHD care suffers. ADHD Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. AAP 2011. Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity. Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. For pharmacologic treatment, the primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation) ADHD Process-of-Care Algorithm, Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition. AAP 2011. Continued systematic monitoring (to include reconsideration of the diagnosis if improvements in symptoms are not apparent) is an on-going process, to be addressed throughout the child’s/adolescent’s care within the practice. Clinicians should regularly monitor all aspects of ADHD treatment, to include: - Systematic reassessment of core symptoms and function; - Regular reassessment of target goals; - Assurance that the family is satisfied with the care they are receiving from other clinicians and therapists, if applicable; - Provision of anticipatory guidance, further child/adolescent and family education, and transition planning as needed and appropriate; - Assurance that care coordination is occurring and meeting the needs of the child/adolescent and family; - Confirmation of adherence to any prescribed medication regimen, with adjustments made as needed; - Heart rate, blood pressure, height, and weight monitoring; and - Continuing to form a therapeutic relationship with the child/adolescent and empower families and children/adolescents to be strong, informed advocates.


ADHD: Symptom Reduction in Follow-up Period for program(s): MUEP (MUC ID: X3280)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. PRO

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: According to the CDC, approximately 9% of children age 4-17 have ADHD and the rate of ADHD diagnosis has increased an average of 5% per year from 2003 to 2007. Evidence exists that shows there is a lack of a standard approach to ADHD diagnosis and adherence to treatment guidelines. One likely cause of the poor provision of ADHD care is the logistical issue surrounding collection of ADHD rating scales from parents and teachers. Collection of rating scales requires knowledge of appropriate ratings scales to use, time to explain the purpose of collecting rating scales to parents, distribution of rating scales to and from home, coordination of distributing and collecting rating scales from school, scoring of completed ratings, and, finally, interpretation of results. This comprises a complex data management process that typically goes un- or under-reimbursed in pediatric settings. Without the collection of these results, the quality of ADHD care suffers. ADHD Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. AAP 2011. Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity. Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. For pharmacologic treatment, the primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation) ADHD Process-of-Care Algorithm, Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition. AAP 2011. Continued systematic monitoring (to include reconsideration of the diagnosis if improvements in symptoms are not apparent) is an on-going process, to be addressed throughout the child’s/adolescent’s care within the practice. Clinicians should regularly monitor all aspects of ADHD treatment, to include: - Systematic reassessment of core symptoms and function; - Regular reassessment of target goals; - Assurance that the family is satisfied with the care they are receiving from other clinicians and therapists, if applicable; - Provision of anticipatory guidance, further child/adolescent and family education, and transition planning as needed and appropriate; - Assurance that care coordination is occurring and meeting the needs of the child/adolescent and family; - Confirmation of adherence to any prescribed medication regimen, with adjustments made as needed; - Heart rate, blood pressure, height, and weight monitoring; and - Continuing to form a therapeutic relationship with the child/adolescent and empower families and children/adolescents to be strong, informed advocates.


Adult Kidney Disease: Referral to Hospice for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3732)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure addressess patient-centered care, end of life care and is a priority for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure that focuses on patient- and family-centered care and end-of life care.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Also tested at individual practice; group practice level

Is the measure currently in use? Yes. QCDR

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi-professional team with expertise in renal palliative care, including nephrology professionals, family or community-based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end-of-life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Adult Kidney Disease: Referral to Hospice for program(s): MSSP (MUC ID: X3732)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Supports appropriate referral to hospice. Reflects coordination and collaboration across ACO.

Does the measure address a critical program objective as defined by MAP? Yes. Encourages coordination across providers and lifespan.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Proposed for multiple federal programs. No

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: Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi-professional team with expertise in renal palliative care, including nephrology professionals, family or community-based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end-of-life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: Related to PQRS measure #380 (intermediate outcome) addressing warfarin use in patients with atrial fibrillation. This measure is duplicative and not harmonized with NQF-endorsed measure under consideration E0555 that applies to a broader population of all patients taking warfarin.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety process eMeasure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. The measure is being tested at the clinician level.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. PQRS measure #380 is an intermediate outcome measure addressing the same population and care process. This measure is also duplicative and not harmonized with NQF-endorsed measure under consideration E0555.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): MUEP (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Adverse Drug Events - Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin for program(s): MSSP (MUC ID: X3485)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Multiple measures related to INR monitoring for certain conditions (e.g., atrial fibrillation). Measures should be harmonized with preference for outcome, including time in therapeutic range.

Does the measure address a critical program objective as defined by MAP? Yes. Improve coordination for patients with chronic conditions

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venous thromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a). However, warfarin is difficult to manage because it has many possible interactions with diet, variability in metabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). The possible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making it imperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory test used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12-month period or at least 1 INR test during each 12-week period of a measurement year. Any patient that does not have at least one INR test result in each 12-week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixaban may be used in place of warfarin for some patients requiring chronic anticoagulation.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): MUEP (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: EHR measure limited to patients aged 15-34 years presenting to ED with trauma - a screening measure with follow-up. Measure is high-priority area for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Screening of ED patients aged 15-34 years with trauma.

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? . It is likely this measure can be applied at a clinician level.

Is the measure currently in use? Yes. This measure is used by the Indian Health Services in its Clinical Reporting System (CRS) National Measures Report and Selected Measures (Local) Report

Does a review of its performance history raise any concerns? No. No performance data available.

Does the measure promote alignment and parsimony? Yes. The measure is already used by the Indian Health Services and could be used across a variety of settings. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is not endorsed, but a similar measure from the PCPI, "Unhealthy Alcohol Use: Screening and Brief Counseling" is endorsed for use at the clinician level.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


Alcohol Screening and Brief Intervention (ASBI) in the ER for program(s): MSSP (MUC ID: X3445)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of health risk with follow-up interventions. However, age cut-off for measure excludes most FFS Medicare population.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Proposed for use across multiple programs. No

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: The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program called ASBI. It targets young, non-dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with an injury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcohol consumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and trauma centers are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder . Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly half of alcohol-related deaths result from motor-vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol-related negative consequences, and injury frequency. 1. http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm 2. Grim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007. 3. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999-2004. National Center for Statistics and Analysis. Washington, D.C. May 2006. 4. National Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www-nrd.nhtsa.dot.gov/Pubs/810616.PDF 5. Maier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1-S2. 6. Rivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962-1964. 7. Dischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877-886. 8. Sanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65-69. 9. Soderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 2007 10. Boyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007. 11. Monti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989-994. 12. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473-483. 13. Schermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29-34. 14. Wilk AI, Jensen NM, and Havighurst TC. “Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274-283. 15. World Health Organization. “A Cross-National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948-955 16. Fleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Brief-Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36-43. 17. Spirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396-404. 18. Bien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315-336. 19. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699-710. 20. Moyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations.” Addiction. 2002; 97: 279-292. 21. Grossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High-Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480. 22. Dinh-Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2. www.thecochranelibrary.com 23. World Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. France, 2007. France. . 24. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627-638. 25. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042-1054. 26. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7): 557-568. 27. United States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007. http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$ string=alcohol 28. Substance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm 29. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville, Maryland. 30. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002. 31. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990. 32. Substance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch3 33. Hungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007. 34. Rose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32-38. 35. Spurling MC and Vinson DC. “Alcohol-Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47-52. 36. Hungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10-s16. 37. McBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156-170. 38. Prochasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102-1114. 39. Longabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817-825. 40. Barnett NP, Lebearu-Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking-Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106-112. 50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701-706. 51. Monti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234-1243. 52. Mello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620-625. 53. Longabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806-816. 54. Hungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14-22. 55. Blose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem-Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571-1575. 56. Dennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007. 57. Gentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541-550.


ALS Multidisciplinary Care Plan Developed or Updated for program(s): MSSP (MUC ID: X2809)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: This measure captures very few Medicare patients.

Does the measure address a critical program objective as defined by MAP? No. 00 new cases /year in US. Average age is 55 years. Average life expectancy is 2-5 years. Not a significant impact on the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No information on testing.

Is the measure currently in use? No. A new measure.Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? .

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? No.

Rationale for measure provided by HHS: In specialized multidisciplinary clinics, patients with ALS receive comprehensive care from a neurologist, pulmonologist, gastroenterologist, physiatrist, social worker, occupational therapist, speech language pathologist, respiratory therapist, specialized nurse case manager, physical therapist, dietitian, psychologist, dentist, and/or palliative care expert.1,2 Moreover, the level of satisfaction with the rendering of the diagnosis and overall satisfaction with care is significantly higher for patients attending a multidisciplinary clinic.2 Specialized clinics coordinate care and interface with a primary care physician, local neurologist and community-based services. Patients who attend specialized ALS clinics are younger and have longer symptom duration than neurology clinic patients, indicating possible referral bias.3 Patient care and survival were examined for 97 patients attending specialized ALS clinics in Italy compared with 124 patients in neurology clinics.4 There was increased utilization of riluzole, percutaneous endoscopic gastrostomy (PEG), and noninvasive ventilation (NIV) in the ALS clinics, and fewer hospital admissions. Mean survival was longer in specialized ALS clinics (1,080 days vs. 775 days, p=0.008). Using COX multivariate analysis, attending an ALS specialized clinic independently predicted longer survival for patients. Prolonged survival (7.5 months, p<0.0001) was found for patients in Ireland attending multidisciplinary ALS clinics.5 Patients at ALS clinics were younger and more likely to receive riluzole (99% vs. 61%). Multidisciplinary care was an independent predictor of survival (p=0.02) and reduced the risk of death by 47% in a 5-year study.5 Dutch patients in multidisciplinary ALS clinics (n=133) were compared with 75 patients receiving general care6 (6). Patients were well-matched and data were collected by a blinded nurse. Patients in multidisciplinary clinic received more aids and appliances (93% vs. 81%, p =0.008) and had higher quality of life (SF-36® Health Survey, p <0.01). Beneficial effects derived from a single visit to a multidisciplinary clinic, suggesting better coordination of care. Importantly, patients attending multidisciplinary clinics had fewer hospital admissions and shorter inpatient stays than those cared for in the community.


Amblyopia Screening in Children for program(s): MUEP (MUC ID: X3817)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligned with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure for children.

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: Vision problems are commonplace among children and adolescents, affecting 25 percent of children five to 17 years of age. Problems specific to children include strabismus, color vision defects, refractive error, reduced visual acuity and amblyopia. Amblyopia, also known as lazy eye, affects nearly 500,000 preschoolers and is the primary cause of permanent vision loss among children of any age. Early detection, treatment and follow-up are critical in preventing and managing vision disorders. Undetected vision problems affect up to 10 percent of preschool-aged children. Fewer than 15 percent of all preschool children receive an eye examination and less than 22 percent of preschool children receive some type of vision screening. Early screening can lead to the detection of amblyopia (2-5%), strabismus (3-4%), and significant refractive error (15-20%), the most prevalent and significant vision disorders of preschool children. The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. The AAP recommends that all children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


Amblyopia Screening in Children for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3817)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. (Grade B)

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure for children.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure designated to report at the clinician level, however no testing data is available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Vision problems are commonplace among children and adolescents, affecting 25 percent of children five to 17 years of age. Problems specific to children include strabismus, color vision defects, refractive error, reduced visual acuity and amblyopia. Amblyopia, also known as lazy eye, affects nearly 500,000 preschoolers and is the primary cause of permanent vision loss among children of any age. Early detection, treatment and follow-up are critical in preventing and managing vision disorders. Undetected vision problems affect up to 10 percent of preschool-aged children. Fewer than 15 percent of all preschool children receive an eye examination and less than 22 percent of preschool children receive some type of vision screening. Early screening can lead to the detection of amblyopia (2-5%), strabismus (3-4%), and significant refractive error (15-20%), the most prevalent and significant vision disorders of preschool children. The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors. The AAP recommends that all children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


Anesthesiology Smoking Abstinence for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3811)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Intermediate outcome measure of smoking cessation at least for the day of surgery. Longer smoking cessation before surgery is better, but cessation on the day of surgery confers some benefit to patients.

Does the measure address a critical program objective as defined by MAP? Yes. This is an intermediate-outcome measure that satisifes a gap area in its' assessment of patients who stop smoking the day of surgery or procedure. An additional measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

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.


Anesthesiology Smoking Abstinence [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3811)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users for program(s): MSSP (MUC ID: X3513)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen.

Does the measure address a critical program objective as defined by MAP? No. Screening measure for population health, though not as relevant to Medicare FFS population. Does not require follow-up intervention if positive. Could be appropriate for duals.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: The U.S. Preventive Services Task Force (USPSTF)40 recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. The most important risk factor for HCV infection is past or current injection drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection status44,45,46,47; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status.


Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users for program(s): MUEP (MUC ID: X3513)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure is already in PQRS and is a high priority quality issue for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Population health screening measure.

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? Yes. This measure promotes alignment with PQRS #387.This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: The U.S. Preventive Services Task Force (USPSTF)40 recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. The most important risk factor for HCV infection is past or current injection drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection status44,45,46,47; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status.


Appropriate age for colorectal cancer screening for program(s): MSSP (MUC ID: X3758)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important area of potential overuse in Medicare population. Need to consider harmonization/selection among competing measures colonoscopy overuse measures.

Does the measure address a critical program objective as defined by MAP? Yes. Reflects potential overuse of importance to Medicare population

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). Overuse of screening colonoscopy in patients age 86 or older is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365).


Appropriate age for colorectal cancer screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3758)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is duplicative of measure under consideration X3769. Harmonizatiopn and consolidation to one measure is needed.

Does the measure address a critical program objective as defined by MAP? Yes. The is an appropriate use population screening measure that complements the PQRS measure #113 (NQF #0034).

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure not yet tested.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No. This is duplicative of measure under consdieration X3769.

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? No.

Rationale for measure provided by HHS: Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow-up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm). In a cohort study of Medicare enrollees from 2000-2008, the authors concluded that one-third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335-1343. doi:10.1001/archinternmed.2011.212). Overuse of screening colonoscopy in patients age 86 or older is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357-2365).


Appropriate follow-up imaging for incidental abdominal lesions for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3759)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value, ppropriate use of imaging measure. in development.

Does the measure address a critical program objective as defined by MAP? . Addresses NQS strategy; Process measure; Accounts for a wide population (18+);

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? No.

Is the measure currently in use? No. No other programs listed.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Incidental kidney, liver, and adrenal lesions are commonly found during abdominal imaging studies, with most of the findings being benign 1,2,3,4, 5. Given the low rate of malignancy, unnecessary follow-up procedures are costly and present a significant burden to patients1,6. To avoid excessive testing and costs, follow-up is not recommended for these small lesions. 1. Pickhardt PJ, Hanson ME, Vanness DJ, et al. Unexpected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology. 2008;249(1):151-159. doi:10.1148/radiol.2491072148. 2. Yee J, Kumar NN, Godara S, et al. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology. 2005;236:519-526. doi:10.1148/radiol.2362040166. 3. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. Am J Roentgenol. 2009;190:1163-1168. doi:10.2214/AJR.07.2799. 4. Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. 2008;249:16-31. doi:10.1148/radiol.2491070783. 5. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754-773. doi:10.1016/j.jacr.2010.06.013. 6. Casarella WJ. A patient’s viewpoint on a current controversy. Radiology. 2002;224(3):927. 7. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. There is considerable variability among radiologists in the management of incidental findings. A 2011 survey 7 conducted by Johnson et al found significant variability in how radiologists report and manage incidental findings. In a more recent survey2 of members of the American College of Radiology, 38% of respondents were aware of the guidance around incidental findings. Among respondents who were aware of the guidance, 89% replied that they were applying the recommendations in their practice. 1. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. 2. Berland LL, Silverman SG, Megibow AJ, Mayo-Smith WW. ACR members’ response to JACR white paper on management of incidental abdominal CT findings. J Am Coll Radiol. 2014;11:30-35. doi:10.1016/j.jacr.2013.06.002.


Appropriate follow-up imaging for incidental abdominal lesions for program(s): MSSP (MUC ID: X3759)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High value measure of potential imaging overuse.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriateness measure for follow-up imaging.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Incidental kidney, liver, and adrenal lesions are commonly found during abdominal imaging studies, with most of the findings being benign 1,2,3,4, 5. Given the low rate of malignancy, unnecessary follow-up procedures are costly and present a significant burden to patients1,6. To avoid excessive testing and costs, follow-up is not recommended for these small lesions. 1. Pickhardt PJ, Hanson ME, Vanness DJ, et al. Unexpected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology. 2008;249(1):151-159. doi:10.1148/radiol.2491072148. 2. Yee J, Kumar NN, Godara S, et al. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology. 2005;236:519-526. doi:10.1148/radiol.2362040166. 3. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. Am J Roentgenol. 2009;190:1163-1168. doi:10.2214/AJR.07.2799. 4. Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. 2008;249:16-31. doi:10.1148/radiol.2491070783. 5. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754-773. doi:10.1016/j.jacr.2010.06.013. 6. Casarella WJ. A patient’s viewpoint on a current controversy. Radiology. 2002;224(3):927. 7. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. There is considerable variability among radiologists in the management of incidental findings. A 2011 survey 7 conducted by Johnson et al found significant variability in how radiologists report and manage incidental findings. In a more recent survey2 of members of the American College of Radiology, 38% of respondents were aware of the guidance around incidental findings. Among respondents who were aware of the guidance, 89% replied that they were applying the recommendations in their practice. 1. Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762-767. doi:10.1016/j.jacr.2011.05.012. 2. Berland LL, Silverman SG, Megibow AJ, Mayo-Smith WW. ACR members’ response to JACR white paper on management of incidental abdominal CT findings. J Am Coll Radiol. 2014;11:30-35. doi:10.1016/j.jacr.2013.06.002.


Appropriate follow-up imaging for incidental thyroid nodules in patients for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3763)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure, appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure, appropriate use measure. Incidental thyroid nodules are common and significant rarely; repeat imaging represents wasted resources.

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.

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: Thyroid nodules are common, with estimates of prevalence as high as 50% 2. Desser and Kamaya3 found that the majority of incidentally noted thyroid nodules were benign with approximately 5% being malignant. Due to the common nature of small thyroid nodules combined with the low malignancy rate, additional follow-up is not recommended (ATA, 2009) 1. 1. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1-48. doi:10.1089/thy.2009.0110. 2. Mortensen JD, Woolner LB, Bennet WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab. 1955;15(10):1270-1280. doi:10.1210/jcem-15-10-1270. 3. Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimaging Clin N Am. 2008;18(3):463-478. doi:10.1016/j.nic.2008.03.005. 4. Ahmed S, Horton KM, Jeffrey RB Jr., Sheth S, Fishman EK. Incidental thyroid nodules on chest CT: review of the literature and management suggestions. Am J Roentgenol. 2010;195:1066-1071. doi:10.2214/AJR.10.4506. In their 2010 review4 of the literature, Ahmed et al concluded that there is significant inconsistency in how incidental thyroid nodules are reported and followed up by radiologists. Given the common nature of thyroid nodules, unnecessary follow-up of these nodules can result in excessive testing and costs for patients.


Appropriate follow-up imaging for incidental thyroid nodules in patients for program(s): MSSP (MUC ID: X3763)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure related to imaging overuse. It may be somewhat narrow for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Measure reflects potential overuse of follow-up imaging.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Thyroid nodules are common, with estimates of prevalence as high as 50% 2. Desser and Kamaya3 found that the majority of incidentally noted thyroid nodules were benign with approximately 5% being malignant. Due to the common nature of small thyroid nodules combined with the low malignancy rate, additional follow-up is not recommended (ATA, 2009) 1. 1. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1-48. doi:10.1089/thy.2009.0110. 2. Mortensen JD, Woolner LB, Bennet WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab. 1955;15(10):1270-1280. doi:10.1210/jcem-15-10-1270. 3. Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimaging Clin N Am. 2008;18(3):463-478. doi:10.1016/j.nic.2008.03.005. 4. Ahmed S, Horton KM, Jeffrey RB Jr., Sheth S, Fishman EK. Incidental thyroid nodules on chest CT: review of the literature and management suggestions. Am J Roentgenol. 2010;195:1066-1071. doi:10.2214/AJR.10.4506. In their 2010 review4 of the literature, Ahmed et al concluded that there is significant inconsistency in how incidental thyroid nodules are reported and followed up by radiologists. Given the common nature of thyroid nodules, unnecessary follow-up of these nodules can result in excessive testing and costs for patients.


Appropriate follow-up imaging for non-traumatic knee pain for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3802)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High value, appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority of making quality care more affordable by developing and spreading new health care delivery models.

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? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Knee pain is common, affecting approximately 13.3% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for knee pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1.Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate follow-up imaging for non-traumatic knee pain for program(s): MSSP (MUC ID: X3802)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. Potentially inappropriate use of advanced imaging. Requires coordination and collaboration across system.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Imaging measure could be used across a range of programs.. No

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: Knee pain is common, affecting approximately 13.3% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for knee pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1.Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate use of imaging for non-traumatic shoulder pain for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3803)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value appropriate use of imaging measure.

Does the measure address a critical program objective as defined by MAP? . Process measure; addresses NQS priority of making quality care more affordable by developing and spreading new health care delivery models.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data.

Is the measure currently in use? No.

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: Shoulder pain is common, affecting approximately 6.7% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Appropriate use of imaging for non-traumatic shoulder pain for program(s): MSSP (MUC ID: X3803)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of imaging overuse relevant to Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. Potentially inappropriate use of advanced imaging. Requires coordination and collaboration across system.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Imaging measure could be used across a range of programs.. No

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: Shoulder pain is common, affecting approximately 6.7% of the U.S. population (1). Radiographs are indicated as part of the initial work-up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One report estimates that 20%-50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (3). 1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984;74:574-579. 2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients should question. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. Accessed March 24, 2014. 3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging. http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008. Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20-35 million. Between 20 and 23% of patients undergoing knee MRI and 27-32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one-quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1) 1. Article in press: Journal of American College of Radiology


Assessment for Psoriatic Arthritis for program(s): MSSP (MUC ID: X3274)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Narrow topic area - better for clinicians/specialists.

Does the measure address a critical program objective as defined by MAP? No. Narrow topic area - better for clincians/specialists.

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

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: The prevalence of psoriatic arthritis (PsA) in the general population of the United States has been estimated to be between 0.1% to 0.25%. Among those with psoriasis, the prevalence of PsA is approximately 10%. This measure encourages dermatologists to actively seek signs and symptoms of PsA at each visit. Quick diagnosis of PsA leads to early treatment which alleviates signs and symptoms of PsA, prevents structural damage, and maximizes quality of life (QOL). As a result regular assessment or PsA which is the goal of this measure has a lot of potential for preventing negative outcomes, for reducing healthcare expenditure and improving outcomes.


Assessment for Psoriatic Arthritis for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3274)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement. 

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap for psoriasis and measure for dermatologists.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No. No testing data available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. This level of analysis is not indicated however, this measure can be applied at the clinican level to evaluate the number of screenings a physician rendered over a defined measurement time period.

Is the measure currently in use? No. No program use information available.

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: The prevalence of psoriatic arthritis (PsA) in the general population of the United States has been estimated to be between 0.1% to 0.25%. Among those with psoriasis, the prevalence of PsA is approximately 10%. This measure encourages dermatologists to actively seek signs and symptoms of PsA at each visit. Quick diagnosis of PsA leads to early treatment which alleviates signs and symptoms of PsA, prevents structural damage, and maximizes quality of life (QOL). As a result regular assessment or PsA which is the goal of this measure has a lot of potential for preventing negative outcomes, for reducing healthcare expenditure and improving outcomes.


Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3783)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety measure for assessing potential overuse of medications. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Measure addresses patient safety.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired (or two part measure) that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III MOH criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose during the measurement period.


Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders for program(s): MSSP (MUC ID: X3783)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired (or two part measure) that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III MOH criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose during the measurement period.


Blood Pressure Screening by age 18 for program(s): MUEP (MUC ID: E1553)

Full Measure Specifications

NQF Number (if applicable): 1553

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: "CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented".

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure improtant for public reporting.

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? No. The steward retired the non-eMEasure from NQF-endorsement because the measure was not being used.

Does the measure promote alignment and parsimony? No. This measure is duplicative and narrower in scope than a measure already finalized in the EHR Incentive programs: ?CMS22v2: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: High blood pressure (hypertension) is a growing concern for children and adolescents in the U.S. due mostly in part to a rapid increase in childhood obesity (Luma, 2006). A recent study of National Health and Nutrition Examination Survey data showed that, during 2003-2006, 2.6 percent of boys and 3.4 percent of girls age eight to 17 years had high blood pressure. Moreover, 13.6 percent of boys and 5.7 percent of girls in this age group had pre-high blood pressure. Overweight boys and obese boys and girls were significantly more likely to have these classifications (Ostchega Y, 2009). Autopsy reports of children and adolescents who have died unexpectedly have shown a positive and significant association with systolic and diastolic blood pressure and body mass index (BMI) (Hayman, 2003). Autopsy reports of adults with high levels of cholesterol and coronary heart disease showed that precursors to these diseases began in childhood (National Cholesterol Education Program). High blood pressure represents a significant financial burden, in 2006, the direct and indirect costs of high blood pressure were estimated at $63.5 billion overall (CDC, 2007). In addition to costs, resource utilization is also significantly higher among hypertensive people. Prescription medicines, inpatient visits, and outpatient visits constitute more than 90 percent of the overall incremental cost of treating hypertension (Balu, 2005). These costs can be expected to rise with increasing prevalence among children.


Blood Pressure Screening by age 18 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E1553)

Full Measure Specifications

NQF Number (if applicable): 1553

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: This measure applies only to 18 year olds - it is redundant with PQRS #317 "Preventive Care and Screening: Screening for High Blood Pressure and Follow up Documented" that captures all patients 18 years and above and includes a follow-up plan for abnormal results.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. During endorsement review the measure testing of record abstraction not as an eMeasure.  

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Measure is specified and tested for the appropriate setting and level of analysis.

Is the measure currently in use? No. Measure currently not in use.

Does the measure promote alignment and parsimony? No. This measure applies only to 18 year olds - it is redundant with PQRS #317  "Preventive Care and Screening: Screening for High Blood Pressure and Follow up Documented" that captures all patients 18 years and above and includes a follow-up plan for abnorma

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure was NQF-endorsed on August 15, 2011, however the steward opted to retire endorsement on August 27, 2014 due to low usage of measure.

Rationale for measure provided by HHS: High blood pressure (hypertension) is a growing concern for children and adolescents in the U.S. due mostly in part to a rapid increase in childhood obesity (Luma, 2006). A recent study of National Health and Nutrition Examination Survey data showed that, during 2003-2006, 2.6 percent of boys and 3.4 percent of girls age eight to 17 years had high blood pressure. Moreover, 13.6 percent of boys and 5.7 percent of girls in this age group had pre-high blood pressure. Overweight boys and obese boys and girls were significantly more likely to have these classifications (Ostchega Y, 2009). Autopsy reports of children and adolescents who have died unexpectedly have shown a positive and significant association with systolic and diastolic blood pressure and body mass index (BMI) (Hayman, 2003). Autopsy reports of adults with high levels of cholesterol and coronary heart disease showed that precursors to these diseases began in childhood (National Cholesterol Education Program). High blood pressure represents a significant financial burden, in 2006, the direct and indirect costs of high blood pressure were estimated at $63.5 billion overall (CDC, 2007). In addition to costs, resource utilization is also significantly higher among hypertensive people. Prescription medicines, inpatient visits, and outpatient visits constitute more than 90 percent of the overall incremental cost of treating hypertension (Balu, 2005). These costs can be expected to rise with increasing prevalence among children.


Breast Cancer Screening for program(s): MSSP (MUC ID: X3797)

Full Measure Specifications

NQF Number (if applicable): 2372

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: Endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines.

Does the measure address a critical program objective as defined by MAP? Yes. High priority risk assessment measure.

Measure development status: Fully developed

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? . Requires testing at clinician/ACO level

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Measure intended for use in multiple public and private sector programs.. Yes

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: Breast cancer is the second most commonly diagnosed cancer among women (after skin cancer). After lung cancer, it causes more deaths in women than any other kind of cancer—there were nearly 40,000 estimated deaths from breast cancer in 2010. Deaths from breast cancer have decreased over the years, in part due to early detection using mammography. On average, mammography will detect about 80-90 percent of breast cancers in women without symptoms (American Cancer Society 2011). Based on evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality with higher benefit in older women (National Cancer Institute 2010). There is a demonstrated reduction in breast cancer mortality due to mammogram screening (National Business Group on Health 2011).


Breast Cancer Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3797)

Full Measure Specifications

NQF Number (if applicable): 2372

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure at the plan and system level. Specifications are consistent with most recent guidelines. Important for dual eligibles. Conditional on testing for reliability and validity at the clincian-level of analysis.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure strongly linked to outcomes.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Setting measure tested: Ambulatory

Is the measure currently in use? No. HEDIS health plan measure.

Does the measure promote alignment and parsimony? . This measure is used in comercial health plans in HEDIS. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Breast cancer is the second most commonly diagnosed cancer among women (after skin cancer). After lung cancer, it causes more deaths in women than any other kind of cancer—there were nearly 40,000 estimated deaths from breast cancer in 2010. Deaths from breast cancer have decreased over the years, in part due to early detection using mammography. On average, mammography will detect about 80-90 percent of breast cancers in women without symptoms (American Cancer Society 2011). Based on evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality with higher benefit in older women (National Cancer Institute 2010). There is a demonstrated reduction in breast cancer mortality due to mammogram screening (National Business Group on Health 2011).


Cellulitis Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0354)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measures are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measure required for VBPM.

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: 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)).


Cervical Cancer Screening for program(s): MSSP (MUC ID: E0032)

Full Measure Specifications

NQF Number (if applicable): 0032

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: A good measure for ACOs in general, but not applicable to the Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Not apllicble to the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The measure has been tested and is in use for health plans.

Is the measure currently in use? Yes. HEDIS health plan measure.Finalized Public Programs: Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults;#Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Quality Reporting System (PQRS);#HRSAFederal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate: HEDIS; Wellpoint; Aetna; AmeriHealth Mercy Family of Companies; Cigna; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsement review - 2012.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Cervical cancer has a high survival rate when detected early, yet it is the second most common cancer among women worldwide (Myers et al. 2008). In the United States, about 12,000 women are diagnosed with cervical cancer each year. In 2010, more than 4,000 women died from cervical cancer (American Cancer Society 2010). For women in whom pre-cancerous lesions have been detected through Pap tests, the likelihood of survival is nearly 100 percent with appropriate evaluation, treatment and follow-up (American Cancer Society 2011). For women under 50 years old, cervical cancer is diagnosed in the early stage 61 percent of the time (American Cancer Society 2010). In 2008, the prevalence of recent Pap test use was lowest among older women, women with no health insurance and recent immigrants (American Cancer Society 2011).


Cervical Cancer Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0032)

Full Measure Specifications

NQF Number (if applicable): 0032

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure at the plan and system level.This is a population measure important to consumers is and consistent with the most recent guidelines. Important for dual eligibles. Conditional on successful testing for reliability and validity at the clinician level.

Does the measure address a critical program objective as defined by MAP? Yes. Population health measure meaningful to consumers.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No. Measure tested at health plan level.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. It is likely this measure can be applied at the clinician level.

Is the measure currently in use? Yes. Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults; Meaningful Use (EHR Incentive Program) - Eligible Professionals; Physician Quality Reporting System (PQRS); HRSA; HEDIS; Wellpoint; Aetna; AmeriHealth Mercy Family of Companies; Cigna; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No. This measure isaligned with new guidelines.

Does the measure promote alignment and parsimony? Yes. Is aligned with commercial health plan programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed this revised measure in 2012. The measure is consistent with the most recent guidelines.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Cervical cancer has a high survival rate when detected early, yet it is the second most common cancer among women worldwide (Myers et al. 2008). In the United States, about 12,000 women are diagnosed with cervical cancer each year. In 2010, more than 4,000 women died from cervical cancer (American Cancer Society 2010). For women in whom pre-cancerous lesions have been detected through Pap tests, the likelihood of survival is nearly 100 percent with appropriate evaluation, treatment and follow-up (American Cancer Society 2011). For women under 50 years old, cervical cancer is diagnosed in the early stage 61 percent of the time (American Cancer Society 2010). In 2008, the prevalence of recent Pap test use was lowest among older women, women with no health insurance and recent immigrants (American Cancer Society 2011).


Chronic Opioid Therapy Follow-up Evaluation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3775)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate follow-up for evaluation of opioid misuse. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of appriate assessment fo opioid misuse.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure is very similar to X3770 Overuse of Opioid Containing Medications for Primary Headache excpt that it applies to all patients on opioids regardless ofd9iagnosis.

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: Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence). In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence). In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence)


Chronic Opioid Therapy Follow-up Evaluation for program(s): MSSP (MUC ID: X3775)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence). In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence). In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence)


Clinical Outcome post Endovascular Stroke Treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3756)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is a high-value outcome measure for patients with stroke.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of those that suffered a stroke. (mRs=  0-2 is a good outcome).

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? N/A. /a

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The standard definition of a good clinical outcome from IA therapy is an mRS score of 0-2 at 90 days as assessed by a certified examiner independent of the interventional physician. 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.


Clinical Outcome post Endovascular Stroke Treatment for program(s): MSSP (MUC ID: X3756)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage further development

Preliminary analysis summary: Important patient-function measure after stroke treatment. Ideally, broader patient population would be preferable for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure reflects good patient function after stroke treatment.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: The standard definition of a good clinical outcome from IA therapy is an mRS score of 0-2 at 90 days as assessed by a certified examiner independent of the interventional physician. 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.


Clinical Response to Oral Systemic or Biologic Medications for program(s): MSSP (MUC ID: X3726)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Important outcome measure for psoriasis. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: A significant proportion of psoriasis patients who are receiving treatment remain unsatisfied with their therapies due to various reasons including lack of or loss of efficacy, side effects, and inconvenience, among others. Treatment dissatisfaction also contributes to patients discontinuing therapy. This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.


Clinical Response to Oral Systemic or Biologic Medications for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3726)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Outcome measure in a new condition area. Conditional on satisfactory testing at the clinician level and submission to NQF for consideration for endorsement. 

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome; fills a gap for dermatologists

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Adds measures for dermatologists

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: A significant proportion of psoriasis patients who are receiving treatment remain unsatisfied with their therapies due to various reasons including lack of or loss of efficacy, side effects, and inconvenience, among others. Treatment dissatisfaction also contributes to patients discontinuing therapy. This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): MUEP (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination.

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? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination measure specific for EHRs that uses Clinical Document Architecture (CDA) that specifies how critical data elements should be encoded for exchange and interoperability.

Does the measure address a critical program objective as defined by MAP? Yes. High-value care coordination measure that uses EHR-specific Clinical Data Architecture (CDA) format for interoperability.

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? . No level of analysis indicated.

Is the measure currently in use? No.

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: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Critical Information Communicated with Request for Referral for program(s): MSSP (MUC ID: X3283)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination is a priority for Medicare patients and a good assement of an ACO.

Does the measure address a critical program objective as defined by MAP? Yes. Care coodination is important for Medicare patients.

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

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: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Closing the Referral Loop - Specialist Report Sent to Primary Care Physician for program(s): MSSP (MUC ID: X3302)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination across providers is a critical program objective.

Does the measure address a critical program objective as defined by MAP? Yes. High priority measure focused on care coordination.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? New eMeasure. No

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: There is evidence that the communication between primary care physicians and specialists is inadequate. This measure intends to improve the communication between primary and specialty care and enhance care continuity.


Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3780)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use for lab tests in the ED.

Does the measure address a critical program objective as defined by MAP? Yes. Assesses broad population; addressed NQS priority of providing better and effective treatment; process measure

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.

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: Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient.


Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding for program(s): MSSP (MUC ID: X3780)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Appropriate use measure.  

Does the measure address a critical program objective as defined by MAP? No. Overuse of uncessary coagulation studies is prevalent.

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

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: Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The Medicare Annual Wellness Visit specifies "detection of any cognitive impairment". Although the USPSTF stated that the evidence is insufficient to recommend screening for cognitive impairment in asymptomatic population though age 80 years and above were not specifically addressed. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Cognitive impairmnet is an important condition for Medicare.

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? . No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. No assessment of alignment in the context of the PQRS-based programs due to lack of testing data and performance information however, this measure addresses a high-priority quality issue in the dual eligible beneficiary population.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): MUEP (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Cognitive Impairment Assessment Among At-Risk Older Adults for program(s): MSSP (MUC ID: X3469)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Dementia is a high priority area for Medicare. Results of cognitive assessment will be captured in EHR. Need to consider insufficient rating from USPSTF due to lack of evidence that early screening or intervention improves outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of health risk for elderly.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documented correlate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing an estimated $157 to $215 billion annually in institutional and home-based long-term care, health care expenses, and unfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step for appropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitive impairment enables effective management of the condition, including interventions to maximize patient safety and plan for future care.


Communication and shared decision-making with patients and families for interventional oncology procedures for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3735)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination and patient-centered measure. A patient-reported outcome measure to assess the patient or family's perspective of the discussion would be of higher value than a documentation measure.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination and patient-centered measure.

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? Yes. No level of analysis identified, however this measure can be applied at the clinican level to account for the number of physicians who provide documentation of discussing the procedure with their patients' families.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: As with any cancer therapy, patients and family members may misunderstand or not know the intent of an interventional oncologic procedure. This measure aims to enhance the patient experience with health care by increasing patient and family understanding of their care and to promote an environment of shared decision-making. The American Society of Clinical Oncology has a similar practice guideline for medical oncologists providing chemotherapy.


Communication and shared decision-making with patients and families for interventional oncology procedures for program(s): MSSP (MUC ID: X3735)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Reflects shared decisionmaking for medically complex patients. Optimally would include patient voice.

Does the measure address a critical program objective as defined by MAP? Yes. Reflects shared decisionmaking in oncology.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

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? No.

Rationale for measure provided by HHS: As with any cancer therapy, patients and family members may misunderstand or not know the intent of an interventional oncologic procedure. This measure aims to enhance the patient experience with health care by increasing patient and family understanding of their care and to promote an environment of shared decision-making. The American Society of Clinical Oncology has a similar practice guideline for medical oncologists providing chemotherapy.


Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3751)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in speciality care measurement.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Currently being specified and tested.

Is the measure currently in use? No. Not currently in use in other programs.

Does the measure promote alignment and parsimony? Yes. This measure would promote alignment by encouraging specality providers to participate in reporting for the 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? No.

Rationale for measure provided by HHS: Implementing this quality measure will lead to a more complete pre-operative evaluation of pelvic organ prolapse (POP) which will result in: 1) more appropriate surgery performed with better surgical outcomes, lower recurrence rates, and fewer re-operations for POP, 2) prevention of unnecessary surgery and 3) improved ability to assess surgical outcomes over time. Reoperation rates for recurrent POP have been shown to be as high as 30%. It is self-evident that if one does not identify a defect in a specific compartment, one is unlikely to correct it. Failure to identify the full extent of POP at the time of initial surgery has been implicated as a significant cause of repeat surgery for POP, as recurrence following the initial surgery commonly occurs early in the post-operative period and often involves a different compartment than that addressed during the initial surgery. ACOG guidelines recommend that when POP surgery is performed defects in all compartments should be addressed using a standardized reproducible exam. Anger et al proposed a series of quality indicators (QI’s) for the purpose of measuring and comparing the care provided to women with prolapse in different clinical settings. The QI’s were based on the Assessing the Care of Vulnerable Elders (ACOVE) project and evaluated using the “RAND Appropriateness Method”. One of the QI’s identified and validated by the panel was: a standardized exam for POP using the Pelvic Organ Prolapse Quantification scale (POP-Q) should be conducted and the prolapse stage of each compartment documented prior to undertaking surgical intervention to correct pelvic organ prolapse. The authors affirmed that objective standardized assessment of vaginal prolapse pre-operatively ensures that the selected procedure is the most appropriate. In addition the POP-Q provides a means of assessing surgical outcomes. Finally, the panel concluded that woman with asymptomatic POP of stage 1 or less should not be offered surgical intervention. The final QI was determined to prevent physicians from offering surgical therapy to women with no indication for surgery. The assignment of Stage 1 prolapse is predicated on conducting an objective standardized exam for vaginal prolapse. (POPQ). In a recent study we found that 67.6% (431/638) of women had a Baden Walker or POP-Q prior to the exam and that 91% of high volume surgeons vs 41% of low volume surgeons completed either a POP-Q or a Baden-Walker formal evaluation of pelvic organ prolapse prior to surgery.


Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair for program(s): MSSP (MUC ID: X3751)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Implementing this quality measure will lead to a more complete pre-operative evaluation of pelvic organ prolapse (POP) which will result in: 1) more appropriate surgery performed with better surgical outcomes, lower recurrence rates, and fewer re-operations for POP, 2) prevention of unnecessary surgery and 3) improved ability to assess surgical outcomes over time. Reoperation rates for recurrent POP have been shown to be as high as 30%. It is self-evident that if one does not identify a defect in a specific compartment, one is unlikely to correct it. Failure to identify the full extent of POP at the time of initial surgery has been implicated as a significant cause of repeat surgery for POP, as recurrence following the initial surgery commonly occurs early in the post-operative period and often involves a different compartment than that addressed during the initial surgery. ACOG guidelines recommend that when POP surgery is performed defects in all compartments should be addressed using a standardized reproducible exam. Anger et al proposed a series of quality indicators (QI’s) for the purpose of measuring and comparing the care provided to women with prolapse in different clinical settings. The QI’s were based on the Assessing the Care of Vulnerable Elders (ACOVE) project and evaluated using the “RAND Appropriateness Method”. One of the QI’s identified and validated by the panel was: a standardized exam for POP using the Pelvic Organ Prolapse Quantification scale (POP-Q) should be conducted and the prolapse stage of each compartment documented prior to undertaking surgical intervention to correct pelvic organ prolapse. The authors affirmed that objective standardized assessment of vaginal prolapse pre-operatively ensures that the selected procedure is the most appropriate. In addition the POP-Q provides a means of assessing surgical outcomes. Finally, the panel concluded that woman with asymptomatic POP of stage 1 or less should not be offered surgical intervention. The final QI was determined to prevent physicians from offering surgical therapy to women with no indication for surgery. The assignment of Stage 1 prolapse is predicated on conducting an objective standardized exam for vaginal prolapse. (POPQ). In a recent study we found that 67.6% (431/638) of women had a Baden Walker or POP-Q prior to the exam and that 91% of high volume surgeons vs 41% of low volume surgeons completed either a POP-Q or a Baden-Walker formal evaluation of pelvic organ prolapse prior to surgery.


Comprehensive Diabetes Care: Eye Exam for program(s): MSSP (MUC ID: E0055)

Full Measure Specifications

NQF Number (if applicable): 0055

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure for diabetes; requires coordination to ensure care delivery and documentation.

Does the measure address a critical program objective as defined by MAP? Yes. Measure requires coordination of care and results to ensure receipt of eye care within ACO.

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? Yes. Finalized Public Programs: Dual Eligibles Core Quality Measures- Captiated Demonstrations;#Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Medicare Part C Plan Rating;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: at least 1 Beacon community; HEDIS; Wellpoint; Aetna; Cigna; Alliance for Health; IHA; AHIP survey - Measures used by a Majority of Health Plans; Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure widely used in public and private applications..

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: Clinically important area for at risk population and aligns with PQRS and MU


Consideration of Non-Pharmacologic Interventions for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3776)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of providing alternative treatment to opioids for pain management. Important for dual eligibles. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority that focuses on promoting the most effective prevention and treatment.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non opioid therapies (strong recommendation, moderate-quality evidence)


Consideration of Non-Pharmacologic Interventions for program(s): MSSP (MUC ID: X3776)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to alternatives to chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non opioid therapies (strong recommendation, moderate-quality evidence)


Controlling High Blood Pressure for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3792)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on testing for reliability and validity at the clinician-level and review by NQF pending final hypertension guidelines from ACC due in 2015.

Does the measure address a critical program objective as defined by MAP? Yes. Intermediate outcome measure for a prevalent condition.

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. HEDIS measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. Inclusion in the PQRS program could promote alignment with the two other programs the measure is currently active in. Inclusion in multiple programs could  enhance the measure's performance and efficiency.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Hypertension is a very significant health issue in the United States. Nearly 78 million adults have high blood pressure. Yet, only fifty three percent of adults with hypertension have their blood pressure under control. The United States spends over $46 billion annually in direct and indirect costs due to high blood pressure. (Go AS, Mozaffarian D, Roger VL et al. 2014) Uncontrolled hypertension can lead to serious complications such as coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease and retinopathy. Among adults with diagnosed diabetes, 71 percent also have hypertension (CDC 2014). Uncontrolled hypertension places adults with diabetes at a higher risk of developing serious complications. Controlling blood pressure has been shown to reduce the probability of undesirable and costly outcomes. The relationship between the measure (control of hypertension) and the long-term clinical outcomes is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke, heart failure, coronary heart disease, diabetes complications and overall mortality (Eighth Joint National Committee).


Controlling High Blood Pressure for program(s): MSSP (MUC ID: X3792)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Intermediate outcome measure for patients 18-85 years. Conditional on review by NQF pending final hypertension guidelines from ACC due in 2015. Existing BP control measure already in MSSP program.

Does the measure address a critical program objective as defined by MAP? Yes. Blood pressure control is a high priority issue for Medicare population.

Measure development status: Fully developed

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? Yes. Needs testing at clinician/ACO level,

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Hypertension is a very significant health issue in the United States. Nearly 78 million adults have high blood pressure. Yet, only fifty three percent of adults with hypertension have their blood pressure under control. The United States spends over $46 billion annually in direct and indirect costs due to high blood pressure. (Go AS, Mozaffarian D, Roger VL et al. 2014) Uncontrolled hypertension can lead to serious complications such as coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease and retinopathy. Among adults with diagnosed diabetes, 71 percent also have hypertension (CDC 2014). Uncontrolled hypertension places adults with diabetes at a higher risk of developing serious complications. Controlling blood pressure has been shown to reduce the probability of undesirable and costly outcomes. The relationship between the measure (control of hypertension) and the long-term clinical outcomes is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke, heart failure, coronary heart disease, diabetes complications and overall mortality (Eighth Joint National Committee).


Coordinating Care - Emergency Department Referrals for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coodination measure of ED provider attempting to contact patient's primary care provider or specialist after a patient is seen with with asthma or chest pain.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination - emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department.?

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? . No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Emergency Department Referrals for program(s): MUEP (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Emergency Department Referrals for program(s): MSSP (MUC ID: X3466)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions. Encourage harmonization with PCPI regarding transition record measure.

Does the measure address a critical program objective as defined by MAP? Yes. Ensures care coordination across multiple settings.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination measure of follow-up within 72 hours after an ED visit for asthma or chest pain.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination -  a follow-up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department.?

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? . No level of analysis indicated.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): MUEP (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

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: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coordinating Care - Follow-Up with Eligible Provider for program(s): MSSP (MUC ID: X3465)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Very promising measure in strategic area; could be broadened to other conditions

Does the measure address a critical program objective as defined by MAP? Yes. Ensures care coordination across multiple settings.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use is inadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow-up (Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al. 2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events.


Coronary Artery Disease (CAD): Antiplatelet Therapy for program(s): MSSP (MUC ID: E0067)

Full Measure Specifications

NQF Number (if applicable): 0067

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Optimal Vascular Care measure (E0076) contains this measure as a component of the composite. Both measures would be redundant.

Does the measure address a critical program objective as defined by MAP? Yes. Heart disease is a prevalent condition for Medicare.

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? Yes. Measure is in PQRS.Finalized Public Programs: Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: AmeriHealth Mercy Family of Companies

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?This measure is a compnent of the OPtimal Vascular Care measure. Both measures would be redundant..

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? No.

Rationale for measure provided by HHS: Clinically important area and aligns with PQRS


Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) for program(s): MSSP (MUC ID: E0070)

Full Measure Specifications

NQF Number (if applicable): 0070

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinical measure that does not reflect MSSP program objectives. Beta blocker persistence ( NQF #71) measure may better reflect care across continuum.

Does the measure address a critical program objective as defined by MAP? No. Important clinical measure for CAD, though does not reflect MSSP program objectives.

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. Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: AmeriHealth Mercy Family of Companies

Does a review of its performance history raise any concerns? Yes. Need current level of performance to assess whether measure is topped out.

Does the measure promote alignment and parsimony? Measure included in multiple programs.. Yes

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: Clinically important area for at risk populations.


Coronary Artery Disease (CAD): Symptom Management: for program(s): MSSP (MUC ID: X1033)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure assesses patient-reported activity and management. Conditional support pending submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. CAD very prevalent in Medicare population. Measure assesses patient-reported activity and management.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Clinically important topic and aligns with PQRS


Depression Remission at Six Months for program(s): MSSP (MUC ID: E0711)

Full Measure Specifications

NQF Number (if applicable): 0711

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Support a depression outcome measure for MSSP. Should align with other federal programs. PQRS measure focused on 12 month remission. Recommend pairing with measure 0712 Use of PHQ9.

Does the measure address a critical program objective as defined by MAP? Yes. High-value outcome measure for depression - prevalent in the Medicare population.

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. Minnesolta Community Measurement: state-wide measure results improved from 5.2% (2009) to 6.9% in 2013.Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Shared Savings ProgramPrivate: MN Community Msmt

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?Outcome measure. The related Depression Remission at 12 months measure is finalized in PQRS..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Patient -reported outcome performance measure (PRO-PM). NQF also endorsed the Depression Remission at 12 months.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The Centers for Disease Control and Prevention states that nationally 15.7% of people report being told by a health care professional that they had depression at some point in their lifetime. Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily. According to National Institute of Mental Health (NIMH), 6.7 percent of the U.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 - 44. Additionally, dysthymia accounts for an additional 3.3 million Americans.


Depression Utilization of the PHQ-9 Tool for program(s): MSSP (MUC ID: E0712)

Full Measure Specifications

NQF Number (if applicable): 0712

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: NQF-endorsed measure intended to be paired with one of two outcome measures - Depression Remission at 6 month and Depresion Remission at 12 months; condiitonal on pairing with either or both outcome measures.

Does the measure address a critical program objective as defined by MAP? Yes. Monitoring tool for patients with depression- a condition prevalent in the Medicare population.

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? Yes. Minnesota Health Scores - Overall rate is 70% for groups/practices.Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: MN Community Msmt

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Only if paired with the outcome measure..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Paired with two outcome measures - Depression Remission at 6 months and Depression Remission at 12 months.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Process measure, administration of the PHQ-9 tool, that is paired with and supports the outcome measures of remission and response


Diabetes: Foot exam for program(s): MSSP (MUC ID: E0056)

Full Measure Specifications

NQF Number (if applicable): 0056

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Diabetes process measure that does not reflect care across continuum or coordination of services.

Does the measure address a critical program objective as defined by MAP? No. Diabetes process measure. Does not reflect program objectives. .

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? Yes. Finalized Public Programs: Meaningful Use (EHR Incentive Program) - Eligible Professionals;#Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate: at least one Beacon community; HEDIS; Wellpoint

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure finalized in multiple programs.. Yes

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: Clinically important area for at risk population and aligns with PQRS and MU


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): MUEP (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient safety eMeasure. Concerns about overtreatment in the elderly resulting in hypoglycemic events are focused on patients aged 75 years and older with comorbidities and cognitive impairment. Important for dual eligibles. Conditional on NQF review and further consideration of evidence for age specifications.

Does the measure address a critical program objective as defined by MAP? Yes. HIgh-value intermediate outcome, patient safety eMeasure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data found.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Diabetes: Hemoglobin A1c Overtreatment in the Elderly for program(s): MSSP (MUC ID: X3476)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Submission to NQF for review. Age cut-off at 65 years needs further review (highly dependent on functional status and related co-morbidities)

Does the measure address a critical program objective as defined by MAP? Yes. Overtreatment and resultant harm is a high priority for Medicare population.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Overuse is a high priority area of measurement across multiple programs. No

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: There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Care coordination for a condition important in Medicare. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Care coordination measure.

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? . No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): MUEP (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of a Health Care Proxy for Patients with Cognitive Impairment for program(s): MSSP (MUC ID: X3468)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Healthcare proxy requires coordination across providers. High priority area for Medicare and MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Dementia is a high priority condition for Medicare frequently requiring coordination across providers.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated, protects the patient from making decisions that they may not understand and provides the practitioner a responsible party with whom to discuss the risks and benefits of care management or planning options. Given that cognitive impairment has significant downstream implications for patient safety and quality of life, measures that encourage patients to take steps that facilitate management and planning of care—including designation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluates whether persons with cognitive impairment, including mild cognitive impairment, have documentation of a health care proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies have found a decline in the ability to consent to medical treatment or decision making as cognitive impairment progresses, suggesting potential constraints to patient preferences if they are unable to communicate decisions relevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes and actual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitive impairment (including—but not limited to—decisions regarding specific care and navigation of the health system overall) and facilitate decision making that reduces aggressive treatments the patient may not want.


Documentation of Signed Opioid Treatment Agreement for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3777)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Limited evidence on effectiveness but recommended by multiple societies. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority that focuses on promoting the most effective prevention and treatment.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COT should include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low-quality evidence). Clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient education (weak recommendation, low-quality evidence)


Documentation of Signed Opioid Treatment Agreement for program(s): MSSP (MUC ID: X3777)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COT should include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low-quality evidence). Clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient education (weak recommendation, low-quality evidence)


Door to puncture time for endovascular stroke treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3747)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: In 2011, the Brain Attack Coalition proposed door-to-treatment times of 2 hours as a benchmark for patients undergoing [endovascular] intra-arterial therapy. Shorter D2P result in better outcomes. Only 52% of all patients in a multicenter registry achieved the targeted D2P time of 2 hours.

Does the measure address a critical program objective as defined by MAP? Yes. This measure is siilar to the door-to balloon time for AMI. Time to treatment is related to patient outcomes.

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? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. This measure would promote alignment as it addresses a specality area of care.

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.


Door to puncture time for endovascular stroke treatment [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3747)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


Evaluation or Interview for Risk of Opioid Misuse for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3774)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety measure screening for opioid misuse in all patients regardless of diagnosis.  Priority for dual eligibles. Conditional on submitting to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety measure screening for risk of opioid miuse.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.  This measure applies to a broader population than MUC X3770.

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: Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low-quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low-quality evidence). A benefit-to-harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low-quality evidence)


Evaluation or Interview for Risk of Opioid Misuse for program(s): MSSP (MUC ID: X3774)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support.

Preliminary analysis summary: Important measure related to appropriateness of chronic opioid therapy. Conditional on measure testing and submission to NQF for endorsement. Multiple opioid measures may be appropriate for MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Important measure related to care for patients with multiple chronic conditions that span settings.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low-quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low-quality evidence). A benefit-to-harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low-quality evidence)


Extravasation of contrast following contrast-enhanced computed tomography (CT) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3523)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value adverse outcome and patient safety measure.

Does the measure address a critical program objective as defined by MAP? Yes. High-value adverse outcome and patient safety measure. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases.

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.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Extravasation of contrast leads to a local inflammatory response that can, in turn, cause acute tissue injury. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases. Extravasation is a relatively common occurrence that affects 1 out of 147 patients who are given intravenous contrast. Elderly patients and small children, as well as patients with limited communication abilities, severe illness or debilitation, or abnormal circulation, are at increased risk for extravasation. 1. American College of Radiology Committee on Drugs and Contrast Media. ACR manual on contrast media- Version 9. 2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69657 intravenous injections. Radiology. 2007;243(1):80-87. doi:10.1148/radiol.2431060554.


Extravasation of contrast following contrast-enhanced computed tomography (CT) for program(s): MSSP (MUC ID: X3523)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important adverse event for hospital setting; may not add value for ACO.

Does the measure address a critical program objective as defined by MAP? Yes. High risk adverse outcome for elderly

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Extravasation of contrast leads to a local inflammatory response that can, in turn, cause acute tissue injury. Patients experiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissue necrosis, and compartment syndrome in extreme cases. Extravasation is a relatively common occurrence that affects 1 out of 147 patients who are given intravenous contrast. Elderly patients and small children, as well as patients with limited communication abilities, severe illness or debilitation, or abnormal circulation, are at increased risk for extravasation. 1. American College of Radiology Committee on Drugs and Contrast Media. ACR manual on contrast media- Version 9. 2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69657 intravenous injections. Radiology. 2007;243(1):80-87. doi:10.1148/radiol.2431060554.


Frequency of inadequate bowel preparation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3760)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patients captured in this measure represent wasted resources.

Does the measure address a critical program objective as defined by MAP? . Patients captured in this measure represent wasted resources.

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? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Poor bowel preparation is a major impediment to the effectiveness of colonoscopy, affecting the ability to detect polyps and influencing the timing of repeat examinations. Given the increased premalignant potential of advanced adenomas, suboptimal bowel preparation may cause an unacceptably high failure rate at identifying these important lesions, thereby compromising the effectiveness of the colonoscopy. Adenoma miss rates in the context of suboptimal bowel preparation are as high as 42%. Poor bowel preparation influences the timing of repeat examination with practitioners recommending follow-up examinations earlier than standard intervals due to inadequate bowel preparation. The economic burden of repeating examinations because of inadequate bowel preparation is substantial. This leads our societies to recommend this measure so individual practitioners can monitor their percentages of examinations requiring repeat because of preparation and compare their percentages to others. We believe that adherence to this measure will result in a reduction of duplicative or unnecessary tests and, therefore, savings to the Medicare program.


Frequency of inadequate bowel preparation for program(s): MSSP (MUC ID: X3760)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure regarding colonoscopy preparation. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Inadequate preparation may reflect lack of coordination and patient-centered instructions.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Poor bowel preparation is a major impediment to the effectiveness of colonoscopy, affecting the ability to detect polyps and influencing the timing of repeat examinations. Given the increased premalignant potential of advanced adenomas, suboptimal bowel preparation may cause an unacceptably high failure rate at identifying these important lesions, thereby compromising the effectiveness of the colonoscopy. Adenoma miss rates in the context of suboptimal bowel preparation are as high as 42%. Poor bowel preparation influences the timing of repeat examination with practitioners recommending follow-up examinations earlier than standard intervals due to inadequate bowel preparation. The economic burden of repeating examinations because of inadequate bowel preparation is substantial. This leads our societies to recommend this measure so individual practitioners can monitor their percentages of examinations requiring repeat because of preparation and compare their percentages to others. We believe that adherence to this measure will result in a reduction of duplicative or unnecessary tests and, therefore, savings to the Medicare program.


Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure for program(s): MSSP (MUC ID: X3481)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures such as patient-reported outcomes in the area of functional status measures. However, this measure needs further development and testing to be ready for implementation.

Does the measure address a critical program objective as defined by MAP? No. This measure addresses two PAC/LTC core concepts of functional and cognitive status assessment, and establishment and attainment of patient/family/caregiver goals. It also addresses a critical program objective for MSSP: Include more high-value measures

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? No. New measureFinalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

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: Goal-setting addresses patient engagement, a high priority of the National Quality Strategy and CMS. Only 4 of 64 measures in the 2014 measure set address this domain. Evidence suggests that physicians rarely conduct functional status assessments for patients with congestive heart failure.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): MSSP (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Meets program objectives. Could be appropriate PROM for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Functional status assessment for chronic pain would meet program objectives.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Patient-reported outcome measure could be used across settings and programs.. No

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: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Support development as a functional patient-reported outcome eMeasure, not just  "score from one of a select list of pain interference assessment tools was recorded at least twice".  A PRO of improvement in pain associated with osteoarthritis fills a needed gap in PROs and functional status measures.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap area in its' assessment of chronic pain due to oseteoarthritis . It is not, however, a functional outcome measure because it only specifies "score from one of a select list of pain interference assessment tools was recorded at le

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. No testing data available.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis for program(s): MUEP (MUC ID: X3053)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: See PQRS eMeasure.

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: Chronic pain affects approximately 116 million adults and costs between $560-$635 billion in healthcare expenses, lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagement and aid providers in managing pain. Goal-setting addresses patient engagement, one of the primary objectives of CMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs for Eligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patient engagement.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): MSSP (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. High-value patient-reported outcome measure for procedure frequently done in the Medicare population.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? High value measure could be used across multiple programs.. No

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: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): MUEP (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3483)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value, patient-reported functional outcome eMeasure.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, patient-reported functional outcome measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? No. No program use information provided.

Does the measure promote alignment and parsimony? . This measure could be adapted to be included in the EHR Incentive Program since the data collected is derived from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): MSSP (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value outcome measure for a procedure frequently performed in the Medicare population.

Does the measure address a critical program objective as defined by MAP? Yes. High-value patient-reported outcome measure for procedure frequently done in the Medicare population.

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

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: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient-reported functional outcome eMeasure.

Does the measure address a critical program objective as defined by MAP? . This is a high-value, patient-reported outcome measure that is important to consumers.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? Yes. This measure is being used by the Veterans Health Administration.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. This measure is currently in use by the Veterans Health Administration and could be adapted to be included in the EHR Incentive Program since the data collected is derived from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements for program(s): MUEP (MUC ID: X3482)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment - from the patient’s perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life.


Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0355)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Cost measures are required for VBPM. Quality measures are needed for GI hemorrhage to match with the cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

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: 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)).


Gout: Serum Urate Monitoring for program(s): MSSP (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: NQF did not approve this eMeasure for trial Use due to lack of evidence of relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? No. Very narrow topic area.

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? Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

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: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Serum Urate Monitoring for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: NQF did not approve this eMeasure for Trial Use due to lack of evidence of relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. New eMeasure submitted to NQF for approval for Trial Use.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Submitted to NQF for possible approval as an eMeasure for Trial Use, i.e., eMeasure that have not been tested in the field but otherwise seem like good measures.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. Measure specified for the clinician level of analysis.

Is the measure currently in use? No. Untested eMeasure considered by NQF for Trial Use.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure was reviewed by NQF and not approved for eMeasure Trial Use.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Serum Urate Monitoring for program(s): MUEP (MUC ID: S2521)

Full Measure Specifications

NQF Number (if applicable): 2521

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes.

Does the measure address a critical program objective as defined by MAP? Yes. New eMEasure submitted to NQF for approval for eMeasure Trial Use in 2014.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. CMS indicates that all EHR measures are being respecified using most recent standards.

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. Adds measures in a new topic area.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF did not approve this measure as an eMeasure for Trial Use due to lack of evidence of a relationship to patient outcomes.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): MSSP (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important clinician measure in gap area. New eMeasure to be tested. Not appropriate for MSSP program.

Does the measure address a critical program objective as defined by MAP? No. Does not meet MSSP objectives. Narrow clinical area.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure approved for trial use.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is the first measure for gout - a condition affecting more than 8 million Americans and affects African Americn men three times more than white men. Important for dual eligibles. NQF-approved eMeasure for Trial Use.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap - there are no other measure for gout.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. NQF-approved eMeasure for Trial Use - no testing yet.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. The measure is specified for the clinician level of analysis.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure could be included in both the PQRS and the EHR Incentive Program since the data collected are dervied from an electronic health record.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Measure has received preliminary approval for " eMeasure Trial-Use" implementaion. Upon receipt of testing data, NQF will re-evaluate this measure for full endorsement.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Gout: Urate Lowering Therapy for program(s): MUEP (MUC ID: S2550)

Full Measure Specifications

NQF Number (if applicable): 2550

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: NQF approved this eMeasure for Trial Use in 2014. Aligns wirth PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Submitted to NQF for approval for eMeasure Trial Use in 2014.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure for Trial Use have not been tested in the field.

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? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF approved this eMeasure for Trial Use in 2014.

Rationale for measure provided by HHS: The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut-off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14-days. The Guidelines recommends dose titration every 2-5 weeks. Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): MSSP (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Health risk screening with follow-up. Could possibly be combined with isolated screening measure (x3512). Most appropriate for duals population.

Does the measure address a critical program objective as defined by MAP? Yes. Health risk assessment with follow-up intervention. Potentially limited applicability to Medicare FFS (except duals).

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process eMeasure of appropriate treatment after a positive HCV screeening test. Suggest combining or pairing with X3512.

Does the measure address a critical program objective as defined by MAP? Yes. Positive screening follow-up measure for Hepatitis C.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. The eMeasure and Health e-Decisions clinical support rules are under development under HHS funding.

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? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: Appropriate Screening Follow-Up for Patients Identified with Hepatitis C Virus (HCV) Infection for program(s): MUEP (MUC ID: X3816)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012) Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV-infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease. Attaining treatment-related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV-infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment-related SVR on the development of HCC among HCV-infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV-infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV-infected persons. Many persons identified as HCV-infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infected persons.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): MSSP (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Isolated health risk screening without follow-up intervention. Could possibly be combined with x3816 that assesses follow-up after positive screen.

Does the measure address a critical program objective as defined by MAP? No. Screening measure for population health, though not as relevant to Medicare FFS population. Does not require follow-up intervention if positive.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): MUEP (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: A?ligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3512)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Population health screening measure aligned with CDC recommendations.

Does the measure address a critical program objective as defined by MAP? Yes. Population health screening for Hepatitis C consistent with CDC recommendations.

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? N/A.

Is the measure currently in use? No. Under development.

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: In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation. Assessment of Risk: Established high-risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth-cohort screening is probably less efficient than risk-based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth-cohort screening is greater than the number who will benefit from risk-based screening. A risk-based approach may miss detection of a substantial proportion of HCV-infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage. In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site-specific testing practices. Studies indicate that even among high-risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk-based testing practices have not been successful in identifying most HCV-infected persons, even those covered by health insurance.


Hip Replacement/ Revision Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0356)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Though surgery measures are finalized in PQRS, additional quality measures specific to hip replacedment are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

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: 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)).


HIV medical visit frequency for program(s): MSSP (MUC ID: E2079)

Full Measure Specifications

NQF Number (if applicable): 2079

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression)

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population.

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? Yes. Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Finalized for PQRS, though low HIV prevalence in broad Medicare FFS population..

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: Retention is a critical component of the HIV care continuum. Although HIV viral suppression is the ultimate outcome of HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap-around supportive services within HIV care.


HIV Screening of STI patients for program(s): MSSP (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important population health measure for general population.

Does the measure address a critical program objective as defined by MAP? No. Low prevalence for Medicare population. Could be appropriate for duals population.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Screening of STI patients for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure overlaps somewhat with X3299 HIV:Ever screened for HIV. This measure, however, focuses on testing at a time of known high-risk as compared to population-based screening. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. High-risk population screening measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Testing is not yet complete. Testing in a group of community health centers that use a commen, certified EHR is forthcoming.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. This measure overlaps somewhat with X3299 HIV:Ever screened for HIV. This measure, however, focuses on testing at a time of known high-risk as compared to population=based screening.

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: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Screening of STI patients for program(s): MUEP (MUC ID: X3300)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. High-risk, population screening measure.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing of persons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIs among those high risk persons who require more frequent testing than the one time testing recommended for the general population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extends the earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs (U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician 2005; 72:2287-2292.), and reiterates the need for more frequent testing of persons at increased risk, including persons who have acquired STIs or request testing for STI.


HIV Viral Load Suppression for program(s): MSSP (MUC ID: E2082)

Full Measure Specifications

NQF Number (if applicable): 2082

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. This intermediate outcome measure preferred to HIV process measures.

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population

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? Yes. Finalized Public Programs: Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Measure in use across multiple federal programs.. Yes

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: Viral load suppression is a critical component of the HIV care continuum and the ultimate outcome of HIV care/treatment. 1. HIV Trialists´ Collaborative Group. Zidovudine, didanosine, and zalcitabine in the treatment of HIV infection: meta-analyses of the randomized evidence. Lancet. Jun 12 1999; 353(9169):2014-2025. 2. Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team. N Engl J Med. Sep 11 1997; 337(11):725-733. 3. Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009; 4(5):e5575. 4. Mocroft A, Vella S, Benfield TL, et al. Changing patterns of mortality across Europe in patients infected with HIV-1. EuroS IDA Study Group. Lancet. Nov 28 1998; 352(9142):1725-1730. 5. Hogg RS, Yip B, Chan KJ, et al. Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA. Nov 28 2001; 286(20):2568-2577. 6. Sterne JA, May M, Costagliola D, et al. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet. Apr 18 2009; 373(9672):1352-1363. 7. Baker JV, Peng G, Rapkin J, et al. CD4+ count and risk of non-AIDS diseases following initial treatment for HIV infection. AIDS. Apr 23 2008; 22(7):841-848. 8. Palella FJ, Jr., Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med. Apr 15 2003; 138(8):620-626. 9. Cain LE, Logan R, Robins JM, et al. When to initiate combined antiretroviral therapy to reduce mortality and AIDS-defining illness in HIV-infected persons in developed countries: an observational study. Ann Intern Med. Apr 19 2011; 154(8):509-515. 10. Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. Jul 15 2010; 363(3):257-265. 11. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009; 360(18):1815-1826. 12. Writing Committee of the CASCADE Collaboration. Timing of HAART initiation and clinical outcomes in human immunodeficiency virus type 1 seroconverters. Arch Intern Med. Sep 26 2011; 171(17):1560-1569. 13. Atta MG, Gallant JE, Rahman MH, et al. Antiretroviral therapy in the treatment of HIV-associated nephropathy. Nephrol Dial Transplant. Oct 2006; 21(10):2809-2813. 14. Schwartz EJ, Szczech LA, Ross MJ, Klotman ME, Winston JA, Klotman PE. Highly active antiretroviral therapy and the epidemic of HIV+ end-stage renal disease. J Am Soc Nephrol. Aug 2005; 16(8):2412-2420. 15. Kalayjian RC, Franceschini N, Gupta SK, et al. Suppression of HIV-1 replication by antiretroviral therapy improves renal function in persons with low CD4 cell counts and chronic kidney disease. AIDS. Feb 19 2008; 22(4):481-487. 16. Calmy A, Gayet-Ageron A, Montecucco F, et al. HIV increases markers of cardiovascular risk: results from a randomized, treatment interruption trial. AIDS. May 15 2009; 23(8):929-939. 17. Kuller LH, Tracy R, Belloso W, et al. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. PLoS Med. Oct 21 2008; 5(10):e203. 18. Torriani FJ, Komarow L, Parker RA, et al. Endothelial function in human immunodeficiency virus-infected antiretroviral naive subjects before and after starting potent antiretroviral therapy: The ACTG (AIDS Clinical Trials Group) Study 5152s. J Am Coll Cardiol. Aug 12 2008; 52(7):569-576. 19. Mellors JW, Rinaldo CR, Jr., Gupta P, White RM, Todd JA, Kingsley LA. Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science. May 24 1996; 272(5265):1167-1170. 20. Vlahov D, Graham N, Hoover D, et al. Prognostic indicators for AIDS and infectious disease death in HIV-infected injection drug users: plasma viral load and CD4+ cell count. JAMA. Jan 7 1998; 279(1):35-40. 21. Anastos K, Kalish LA, Hessol N, et al. The relative value of CD4 cell count and quantitative HIV-1 RNA in predicting survival in HIV-1-infected women: results of the women´s interagency HIV study. AIDS. Sep 10 1999; 13(13):1717-1726. 22. O´Brien TR, Blattner WA, Waters D, et al. Serum HIV-1 RNA levels and time to development of AIDS in the Multicenter Hemophilia Cohort Study. JAMA. Jul 10 1996; 276(2):105-110. 23. Egger M, May M, Chene G, et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. Jul 13 2002; 360(9327):119-129. 24. Anastos K, Barron Y, Cohen MH, et al. The prognostic importance of changes in CD4+ cell count and HIV-1 RNA level in women after initiating highly active antiretroviral therapy. Ann Intern Med. Feb 17 2004; 140(4):256-264. 25. O´Brien WA, Hartigan PM, Martin D, et al. Changes in plasma HIV-1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS. N Engl J Med. Feb 15 1996; 334(7):426-431. 26. Hughes MD, Johnson VA, Hirsch MS, et al. Monitoring plasma HIV-1 RNA levels in addition to CD4+ lymphocyte count improves assessment of antiretroviral therapeutic response. ACTG 241 Protocol Virology Substudy Team. Ann Intern Med. Jun 15 1997; 126(12):929-938. 27. Chene G, Sterne JA, May M, et al. Prognostic importance of initial response in HIV-1 infected patients starting potent antiretroviral therapy: analysis of prospective studies. Lancet. Aug 30 2003; 362(9385):679-686. 28. Deeks SG, Gange SJ, Kitahata MM, et al. Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America. Clin Infect Dis. Nov 15 2009; 49(10):1582-1590. 29. Quinn TC, Wawer MJ, Sewankanbo N, et al. for the Rakai Project Study Group. Viral Load and heterosexual transmission of human immunodeficiency virus type-1. NEJM 2000;342:921-929. 30. Chakraborty H., Sen, PK, Helms, RW, et.al. Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621-7. 31. Baeten JM, Kahle E, Lingappa JR, et al, Partners in Prevention HSV/HIV Transmission Study Team. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Sci Transl Med. 2011 Apr 6;3(77):77ra29. 32. Gulick RM, Mellors JW, Havlir D, et al. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretroviral therapy. N Engl J Med. 1997 Sep 11;337(11):734-9. 33. Zhang H, Dornadula G, Beumont M, et al. Human immunodeficiency virus type 1 on the semen of men receiving highly active antiretroviral therapy. N Engl J Med 1998;339:1803-1809. 34. Vernazza PL, Troiani L, Flepp MJ, et al, The Swiss HIV Cohort Study. Potent antiretroviral treatment of HIV-infection results in suppression of the seminal shedding of HIV. AIDS. 2000 Jan 28;14(2):117-21. 35. Cu-Uvin S, Caliendo AM, Reinert S, et al. Effect of highly active antiretroviral therapy on cervicovaginal HIV-1 RNA. AIDS. 2000 Mar 10;14(4):415-21. 36. Kotler DP, Shimada T, Snow G, et al. Effect of combination antiretroviral therapy upon rectal mucosal HIV RNA burden and mononuclear cell apoptosis. AIDS. 1998 Apr 16;12(6):597-604. 37. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493-505. 38. Hughes JP, Baeten JM, Lingappa JR, et al. Determinants of Per-Coital-Act HIV-1 Infectivity Among African HIV-1-Serodiscordant Couples. J Infect Dis. Feb 2012;205(3):358-365. transmission of HIV-1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621-7.


HIV: Ever screened for HIV for program(s): MSSP (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Measure not appropriate for FFS Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Screening measure does not include Medicare population. Could be appropriate for duals population.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


HIV: Ever screened for HIV for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. The measure is also important to dual eligibles under age 65 years.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure closely linked to outcomes.  Applies only to ages 15-65 years.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. This measure is not yet tested. Testing in a group of community health centers that use certified EHR's systems is noted as upcoming.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. N/A

Is the measure currently in use? No. As noted on MUC list: A similar measure has been in use at the VA for over five years and at IHS for 2 years.

Does the measure promote alignment and parsimony? Yes. This measure could be used in a variety of clinician-based settings and would promote alignment. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


HIV: Ever screened for HIV for program(s): MUEP (MUC ID: X3299)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening measure.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: Increasing the number of HIV-infected persons who are aware of their serostatus is an important component of the National HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk for progression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013)


Imaging in adult ED patients with minor head injury for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3764)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure of appropriate use. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. 

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: This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.


Imaging in adult ED patients with minor head injury for program(s): MSSP (MUC ID: X3764)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure of appropriateness for MSSP. Need to consider competing measures related to ED imaging (NQF#0668).

Does the measure address a critical program objective as defined by MAP? Yes. Relates to critical program object related to appropriateness of ED imaging.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.


Imaging in pediatric ED patients aged 2 through 17 years with minor head injury for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3778)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value measure of appropriate use in the emergency dept. Inappropriate use of imaging results in increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.

Does the measure address a critical program objective as defined by MAP? . Process measure; addresses NQS priority that focusses on making quality care more affordable by developing/spreading new health care delivery models

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? No.

Is the measure currently in use? No. This measure is aligned with ACEP's Choosing Wisely recommendations, and is also aligned with the Pediatric Emergency Care Applied Research Network (PECARN), but is not found to be in use in any federal or private programs.

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 measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. A new study in JAMA demonstrated to a growing trend in ED visits for TBI, with adults older than 60 years accounting for the largest increase in rates.


In-hospital mortality following elective open repair of AAAs for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E1523)

Full Measure Specifications

NQF Number (if applicable): 1523

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: High-level outcome measure that is fully developed and NQF-endorsed.

Does the measure address a critical program objective as defined by MAP? Yes. High-value outcome measure; addresses NQS priority of making care safer by reducing harm caused in the delivery of care.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at clincian, group, practice and facility levels.

Is the measure currently in use? Yes. Vascular Study Group of New England registry

Does a review of its performance history raise any concerns? No.

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: 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.


In-hospital mortality following elective open repair of AAAs [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: E1523)

Full Measure Specifications

NQF Number (if applicable): 1523

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Patient safety process eMeasure applied to all patients on warfarin. NQF has endorsed this measure but has not considered the eMeasure. Related to PQRS #380 about the time an atrial fibriallation patient's INR is in the correct range (intermediate outcome). This measure under consideration captures the broadest population of all patients taking warfarin regardless of diagnosis. In view of multiple measures for warfarin management and to promote harmonization and parsimony suggest focusing on a process (monitoring INR) and an intermediate outcome (time in therapeutic range) measure for all patients taking warfarin.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety eMeasure of appropriate medication monitoring.

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? N/A.

Is the measure currently in use? Yes.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF has not considered the eMeasure version of this measure.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): MUEP (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS measure.

Measure development status: Field testing

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. NQF has not considered the eMeasure version of this measure.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


INR Monitoring for Individuals on Warfarin (e-specified version of NQF #0555) for program(s): MSSP (MUC ID: E0555)

Full Measure Specifications

NQF Number (if applicable): 0555

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Appropriate for MSSP program. Requires coordination of care across providers. If possible, should incorporate outcome for time in therapeutic range.

Does the measure address a critical program objective as defined by MAP? Yes. High risks associated with warfarin use. Broad population measure across conditions. Requires coordination of care across providers.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis?

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Competing anticoagulation measures across conditions and programs should be reconciled..

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? No.

Rationale for measure provided by HHS: The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is a vitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “further thromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deep vein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrow therapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patient to stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval by the Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Food and Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued in the United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement are envisioned with the implementation of this measure. Specifically, the measure will help providers identify individuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INR testing for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) and therefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality. Recently published evidence from a large (n=56,490) well-designed study suggests that patients with two or more gaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001) than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson et al., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid-point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines: • Holbrook et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (page e153S): 3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs) 3.1. For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B). • Anderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918): 1. Management 1.1. Pharmacological and Nonpharmacological Therapeutic Options 1.1.2. Preventing Thromboembolism 5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Class I; Level of Evidence: A)


Intimate Partner (Domestic) Violence Screening for program(s): MSSP (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure excludes most Medicare patients; could be appropriate for duals

Does the measure address a critical program objective as defined by MAP? No. Assesses health risk without follow-up intervention. Age cut-off for measure excludes most FFS Medicare population.

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? Yes.

Is the measure currently in use? Yes (Indian Health Service). Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Intimate Partner (Domestic) Violence Screening for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: USPSTF recommends screening for intimate partner violence in all women of childbearing age (Grade B).

Does the measure address a critical program objective as defined by MAP? Yes. The measure is high value because it focuses on population health and vulnerable populations (screening for domestic violence). 

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure requires updates to new EHR standards.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A.

Is the measure currently in use? Yes. The measure is currently used by the Indian Health Services to screen high-risk NAtive Americans.

Does a review of its performance history raise any concerns? No. The IHS 2012 goal was to achieve the rate of 55.3% for the proportion of female patients aged 15-40 who receive screening for domestic violence. IHS exceeded the goal by reaching 61.5%.: (from the IHS website)

Does the measure promote alignment and parsimony? Yes. The measure is already in use in the Indian Health Program. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Intimate Partner (Domestic) Violence Screening for program(s): MUEP (MUC ID: X3446)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Aligns with PQRS.

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? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect in American Indian and Alaska Native communities. In the United States, 30% of women experience domestic violence at some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the national average. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experienced physical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physical abuse from a male partner at least once in their lives. The consequences of intimate partner violence to the health of a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations on intimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or refer women who screen positive to intervention services. IPV is common in the United States but often remains undetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing the most severe types of in their lifetime (1-3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12-14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15-19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age. Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1-24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company. National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm


Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0351)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measures are needed to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures are required for VBPM.

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: 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): Physician Feedback/VBPM (MUC ID: X0352)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Can be matched with 3 finalized measures for knee replacement in PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures required for the VBPM.

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: 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)).


MD Multidisciplinary Care Plan Developed or Updated for program(s): MSSP (MUC ID: X3791)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important specialty measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: A systematic review of muscular dystrophies has highlighted the medical complexity of caring for patients with MD. Such patients may develop cardiac, pulmonary, nutritional, and musculoskeletal complications that require the assistance of cardiologists, pulmonologists, orthopedists, physiatrists, physical therapists, occupational therapists, nutritionists, orthotists, and speech pathologists, in addition to neurologists. Additionally, myopathies with a limb-girdle, humeroperoneal, or distal pattern of weakness may be challenging to diagnose. A specific diagnosis provides patients with “closure,” assists genetic counseling, and directs monitoring for complications and optimal management.


MD Multidisciplinary Care Plan Developed or Updated for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3791)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: The 5 prior MUCs for muscular dystrophy are more specific aspects of the care plan. This process measure may add little. Conditional on testing at the clincian-level and evaluating usefulness to potential audiences.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in the measurement of speciality providers (neurologists).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. The measure is not in use in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: A systematic review of muscular dystrophies has highlighted the medical complexity of caring for patients with MD. Such patients may develop cardiac, pulmonary, nutritional, and musculoskeletal complications that require the assistance of cardiologists, pulmonologists, orthopedists, physiatrists, physical therapists, occupational therapists, nutritionists, orthotists, and speech pathologists, in addition to neurologists. Additionally, myopathies with a limb-girdle, humeroperoneal, or distal pattern of weakness may be challenging to diagnose. A specific diagnosis provides patients with “closure,” assists genetic counseling, and directs monitoring for complications and optimal management.


MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3771)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate treatment for acute migraines attacks. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? . Appropriate treament related to outcomes. Applies to 12 years of age and up.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: Migraine is under diagnosed and suboptimally treated in the majority of patients. The Work Group noted although there are no guidelines available, almotriptan is approved for ages 12-17 and rizatriptan was recently approved by the FDA for ages 6-17. The Work Group also noted that although the triptans in individuals less than 12 years old may be prescribed off label, there is limited or no evidence to support this.


MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK for program(s): MSSP (MUC ID: X3771)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Migraine is under diagnosed and suboptimally treated in the majority of patients. The Work Group noted although there are no guidelines available, almotriptan is approved for ages 12-17 and rizatriptan was recently approved by the FDA for ages 6-17. The Work Group also noted that although the triptans in individuals less than 12 years old may be prescribed off label, there is limited or no evidence to support this.


Migraine Or Cervicogenic Headache Related Disability Functional Status for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3796)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: This process measure documents functional status assessment. A better measure would determine whether the disability functional status score remained the same or improved during a recent timeframe simiar to MUC X3786 for Quality of Life. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap area for the measurement of speciality care.?

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure tested for appropriate level.

Is the measure currently in use? No. Measure not in use in other programs

Does the measure promote alignment and parsimony? .

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? No.

Rationale for measure provided by HHS: The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the system level to indicate where improvements in the management and treatment of patients with headache should be made.


Migraine Or Cervicogenic Headache Related Disability Functional Status for program(s): MSSP (MUC ID: X3796)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the system level to indicate where improvements in the management and treatment of patients with headache should be made.


Nutritional Status or Growth Trajectories Monitored for program(s): MSSP (MUC ID: X3801)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Delayed growth, short stature, muscle wasting and increased fat mass are characteristics of DMD and impact on nutritional status and energy requirements. The early introduction of steroids has altered the natural history of the disease, but can exacerbate weight gain in a population already susceptible to obesity. Prior to commencing steroids, anticipatory guidance for weight management should be provided. Malnutrition is a feature of end stage disease requiring a multidisciplinary approach, such as texture modification and supplemental feeding. As a result of corticosteroid treatment, vitamin D and calcium should be supplemented. Patients with MD may have difficulty receiving adequate oral intake due to dysphagia and/or inability to feed themselves due to excessive arm weakness. Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life. When oral intake is inadequate, other means of maintaining intake, such as gastrostomy or jejunostomy feeding tubes, may be needed to maintain optimal nutrition. There is evidence from related conditions (amyotrophic lateral sclerosis [ALS]) that maintenance of nutrition and body weight prolongs survival.


Nutritional Status or Growth Trajectories Monitored for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3801)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life in patietns with muscular dystrophy. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in the measurement of speciality care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Delayed growth, short stature, muscle wasting and increased fat mass are characteristics of DMD and impact on nutritional status and energy requirements. The early introduction of steroids has altered the natural history of the disease, but can exacerbate weight gain in a population already susceptible to obesity. Prior to commencing steroids, anticipatory guidance for weight management should be provided. Malnutrition is a feature of end stage disease requiring a multidisciplinary approach, such as texture modification and supplemental feeding. As a result of corticosteroid treatment, vitamin D and calcium should be supplemented. Patients with MD may have difficulty receiving adequate oral intake due to dysphagia and/or inability to feed themselves due to excessive arm weakness. Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life. When oral intake is inadequate, other means of maintaining intake, such as gastrostomy or jejunostomy feeding tubes, may be needed to maintain optimal nutrition. There is evidence from related conditions (amyotrophic lateral sclerosis [ALS]) that maintenance of nutrition and body weight prolongs survival.


Optimal Asthma Care 2014 for program(s): MUEP (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

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: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Asthma Care 2014 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Composite outcome measure important to consumers. The measure has been revised to address concerns raised by NQF Steering Committee. Conditional on revised measure being submitted to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: composite, outcome; important to consumers (submitted by the Consumer-Purchaser Alliance)

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in group/practice setting. Full specifications available at http://www.health.state.mn.us/healthreform/measurement/proposedrule/msr813prp04oac.pdf.

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. NQF reviewed this measure as a new submission in 2012. The Steering Committee did not recommend the measure at that time but thought it would ultimately be an important measure. Concerns were raised about evidence for the written management plan componen

Rationale for measure provided by HHS: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Asthma Care 2014 for program(s): MSSP (MUC ID: X3773)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important composite measure with patient-reported outcome measure component measure. Updated measure will be submitted to NQF for endorsement review.

Does the measure address a critical program objective as defined by MAP? Yes. Important composite measure, including Patient Reported Outcome Measure for asthma.

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 (in Minnesota). Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Composite measure provides a more comprehensive view of care.. No

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: Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); within population subgroups it was higher among females, children, persons of non-Hispanic black and Puerto Rican race or ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwest regions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma. In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons. Despite the high burden from adverse impacts, use of some asthma management strategies based on clinical guidelines for the treatment of asthma remained below the targets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations.


Optimal Vascular Care for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0076)

Full Measure Specifications

NQF Number (if applicable): 0076

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Revised composite outcome measure (removed the lipid component due to new guidelines) to replace the prior version finalized in PQRS. Conditional on the revised measure being submitted for NQF endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. High value measure: composite, outcomes

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. No testing data available.

Is the measure currently in use? Yes. Publicly reported in Minnesota: http://www.mnhealthscores.org/medical-group-measure-detail/vascular-disease-0/#/results  

Does a review of its performance history raise any concerns? No. Recent change to specifications to remove the lipid component. No updated performance data available.  Prior version with 4 compnents: state average about 50%

Does the measure promote alignment and parsimony? Yes. This measure replaces the prior version of the measure that has been used in PQRS.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed the previous version of this measure that included the lipid outcome component. This revised measure has removed that component due to changes in the guidelines. The revised measure should be submitted to NQF.

Rationale for measure provided by HHS: According to the MN Department of Health, vascular disease is a high impact clinical condition in Minnesota. More than 20% of all deaths in Minnesota are due to heart disease and more than 6% are due to stroke, making them the second and third leading causes of death, respectively, in the state behind cancer. Inpatient hospitalization charges alone in Minnesota were more than $1.85 billion for heart disease patients and $362 million for stroke patients in 2008. Risk factors reported by Minnesotans include 34% high blood cholesterol, 22% high blood pressure, 16.7% cigarette smoke, 6.7% diabetes, 62% overweight, and 16% physical inactivity. 1a.4 Citations for Evidence of High Impact: Minnesota Department of Health 2010 Fact Sheets on Heart Disease and Stroke in Minnesota; http://www.health.state.mn.us/divs/hpcd/chp/cvh/Data.htm


Optimal Vascular Care for program(s): MSSP (MUC ID: E0076)

Full Measure Specifications

NQF Number (if applicable): 0076

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Composite outcome measure for highly prevalent condition important to Medicare patients. Conditonal on successful maintenace review of revised measure by NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value composite outcome measure for coronary artery disease - a highly prevalent condition in the Medicare population.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. In use in Minnesolta.

Is the measure currently in use? Yes. Minnesota Quality Scores.Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate: Buying Value core ambulatory measure

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? ?This composite outcome measure would address the same aspects of care as multiple, individual outcome and process measures..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. NQF endorsed a previous version with 4 components (lipd component has since been removed to align with new guidelines).

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: According to the MN Department of Health, vascular disease is a high impact clinical condition in Minnesota. More than 20% of all deaths in Minnesota are due to heart disease and more than 6% are due to stroke, making them the second and third leading causes of death, respectively, in the state behind cancer. Inpatient hospitalization charges alone in Minnesota were more than $1.85 billion for heart disease patients and $362 million for stroke patients in 2008. Risk factors reported by Minnesotans include 34% high blood cholesterol, 22% high blood pressure, 16.7% cigarette smoke, 6.7% diabetes, 62% overweight, and 16% physical inactivity. 1a.4 Citations for Evidence of High Impact: Minnesota Department of Health 2010 Fact Sheets on Heart Disease and Stroke in Minnesota; http://www.health.state.mn.us/divs/hpcd/chp/cvh/Data.htm


Overuse of Barbiturate Containing Medications for Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3765)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Appropriate use measure, but title is misleading since the measure assess the percentage of patients NOT prescribed barbiturates rather than first line drugs. Conditional on submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure addressing inappropriate use of barbiturates rather than first line drugs.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. However, barbiturates or butalbital containing agents are prescribed frequently. The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. One study noted that barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to a tertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%).


Overuse of Barbiturate Containing Medications for Primary Headache Disorders for program(s): MSSP (MUC ID: X3765)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. However, barbiturates or butalbital containing agents are prescribed frequently. The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. One study noted that barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to a tertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%).


Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3785)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Appropriate use measure.  Conditional on testing at the clincian level and submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriate use measure for imaging.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. MUC list does not note level of testing?

Is the measure currently in use? No. Not used in other programs

Does the measure promote alignment and parsimony? No.

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? No.

Rationale for measure provided by HHS: Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.


Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination for program(s): MSSP (MUC ID: X3785)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Conditional on measure testing and submission to NQF for endorsement. Multiple headache measures may be appropriate for a MSSP composite.

Does the measure address a critical program objective as defined by MAP? Yes. Potential inappropriate imaging for headache.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.


Overuse Of Opioid Containing Medications For Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3770)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: Duplicative of measure underconsideration X3774 for patients taking opioid regardless of diagnosis.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure measure for assessment of opiod overuse.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. Duplicative and less specific than measure under consideration X3774 that specifies use of a screening tool and applies to all opioid users, not just patients with headaches.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. The use of barbiturates or opioids increases the risk of chronic daily headache and drug induced hyperalgesia. In one study, any use of barbiturates and opiates was associated with increased risk of transformed migraine after adjusting for covariates, while triptans were not. In a sample of 5,796 people with headache, 4,076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users.


Overuse Of Opioid Containing Medications For Primary Headache Disorders for program(s): MSSP (MUC ID: X3770)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. The use of barbiturates or opioids increases the risk of chronic daily headache and drug induced hyperalgesia. In one study, any use of barbiturates and opiates was associated with increased risk of transformed migraine after adjusting for covariates, while triptans were not. In a sample of 5,796 people with headache, 4,076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users.


Patient Counseled About Health Care Decision-Making for program(s): MSSP (MUC ID: X3789)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: An important aspect of ongoing management includes proactively preparing patients with MD and their families for the long-term consequences of muscular dystrophies and engaging in discussions regarding end-of-life care. This helps patients come to terms with their condition and prepare for the expected complications of their form of MD and avoids the need for hasty decisions made in the throes of a medical crisis. Palliative care is useful to alleviate the suffering of these patients.


Patient Counseled About Health Care Decision-Making for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3789)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Care coordination addressing advanced directives and end-of life planning.  Important for dual eligibles. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Fills a gap in a new condition area.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No level of analysis indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? Yes. This measure addresses a high-priority quality issue in the dual eligible beneficiary population.

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: An important aspect of ongoing management includes proactively preparing patients with MD and their families for the long-term consequences of muscular dystrophies and engaging in discussions regarding end-of-life care. This helps patients come to terms with their condition and prepare for the expected complications of their form of MD and avoids the need for hasty decisions made in the throes of a medical crisis. Palliative care is useful to alleviate the suffering of these patients.


Patient Queried about Pain and Pain Interference with Function for program(s): MSSP (MUC ID: X3800)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Between 68-82% of patients with muscular dystrophies live in pain. Pain is a common feature of some MDs, notably myotonic dystrophy and FSHD, but also many of the limb girdle muscular dystrophies (LGMDs). Pain interferes with physical and psychological functioning in these patients. Lower extremity pain intuitively affects ambulation. Pain and fatigue are independent predictors of lower physical functioning and greater depression. Thus identification and treatment of pain is important to improve the care of patients with MD.


Patient Queried about Pain and Pain Interference with Function for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3800)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Process measure addresses systematic assessment for pain. Conditional on successful testing at the clinican level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure satisfies a gap area in its' assessment of muscular dystrophy and promotes partcicipation among eligible professionals. 

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The level of analysis is not indicated.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Between 68-82% of patients with muscular dystrophies live in pain. Pain is a common feature of some MDs, notably myotonic dystrophy and FSHD, but also many of the limb girdle muscular dystrophies (LGMDs). Pain interferes with physical and psychological functioning in these patients. Lower extremity pain intuitively affects ambulation. Pain and fatigue are independent predictors of lower physical functioning and greater depression. Thus identification and treatment of pain is important to improve the care of patients with MD.


Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy for program(s): MSSP (MUC ID: X3787)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: DMD is a recessive X- linked genetic disorder characterized by progressive muscle weakness and reduced muscle tone. Affecting only boys, it limits life expectancy to approximately 20 years. Care for patients with DMD is poorly standardized. This leads to inequality in access to treatment. Although there is no cure, a Cochrane Review and AAN practice parameter concluded that prednisone may provide short term effective treatment that prolongs the ability to walk, reduces the complications such as scoliosis, respiratory insufficiency and cardiac impairment. Despite the well documented beneficial effects of corticosteroids in DMD, a population based study of corticosteroid use between 1991 and 2005 reported that only 50.9% of individuals had ever been on corticosteroids. The annual mean percent corticosteroid use varied widely from 8.4% to 80.2% across clinics. Another survey showed that nearly 10% of neuromuscular disease clinics do not offer such therapy. Glucocorticoids are currently the only medication available that slows the decline in muscle strength and function in DMD, which in turn reduces the risk of scoliosis and stabilizes pulmonary function. Approximately 16% of Muscular Dystrophy Association clinic directors report not using corticosteroids.


Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3787)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Muscular dystrophy is a group of nine inherited diseases of progressive muiscle weakness affecting more than 50,000 Americans. This process measure in new condition area measures use of evidence-based therapy that can slow the progression of the disease. Conditional on satisfactory testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in speciality care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. There are no notes on level of analysis.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by allowing the participation of speciality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: DMD is a recessive X- linked genetic disorder characterized by progressive muscle weakness and reduced muscle tone. Affecting only boys, it limits life expectancy to approximately 20 years. Care for patients with DMD is poorly standardized. This leads to inequality in access to treatment. Although there is no cure, a Cochrane Review and AAN practice parameter concluded that prednisone may provide short term effective treatment that prolongs the ability to walk, reduces the complications such as scoliosis, respiratory insufficiency and cardiac impairment. Despite the well documented beneficial effects of corticosteroids in DMD, a population based study of corticosteroid use between 1991 and 2005 reported that only 50.9% of individuals had ever been on corticosteroids. The annual mean percent corticosteroid use varied widely from 8.4% to 80.2% across clinics. Another survey showed that nearly 10% of neuromuscular disease clinics do not offer such therapy. Glucocorticoids are currently the only medication available that slows the decline in muscle strength and function in DMD, which in turn reduces the risk of scoliosis and stabilizes pulmonary function. Approximately 16% of Muscular Dystrophy Association clinic directors report not using corticosteroids.


PC-02 Cesarean Section (Provider Level) for program(s): MSSP (MUC ID: X3788)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important measure. Not appropriate for Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Important appropriateness measure. Not appropriate for Medicare FFS population

Measure development status: Fully developed

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? Yes. Needs clinician level testing.

Is the measure currently in use? Yes (at provider level only). Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Fully aligned provider and clinician level measure would contribute to efficient use of measurement resources.. No

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: This AMA – PCPI measure is harmonized with the Joint Commission’s measure (PC-02 Cesarean Section) in language and intent. The Joint Commission measure is a facility-level measures whereas this measure includes attribution at the individual provider level measure Cesarean deliveries are performed for many reasons. Some, such as those for breech presentation, are supported by strong clinical consensus. However, many cesareans, especially those done in the course of labor, are the result of labor management practices that vary widely and suggest clinician discretion (CMQCC) There is growing evidence to support the claim that provider-dependent indications (i.e., those that rely on provider judgment) combined with provider discretion contribute significantly to the overall increase in both primary and repeat cesareans. The fact that cesarean delivery rates and practices vary widely among states, regions, hospitals, and providers for both primary and repeat cesareans demonstrates that hospitals and clinicians can differ in their responses to the same conditions. This fact suggests the need for more precise clinical practice guidelines and/or greater accountability and incentives for following them. (California Maternal Quality Care Collaborative) California Maternal Quality Care Collaborative clinician interviews (funded by California HealthCare Foundation) reveal that many nurses talked about the timing of cesareans done during labor, citing the competing demands on physicians for clinic appointments and their desire for balance between work and the rest of life. Institutional pressures and the pace of high-volume facilities was another factor mentioned, along with physicians’ impatience with labor progress—a response that can be exacerbated in clinicians and mothers alike by the use of inductions, which can set up an expectation for a quick birth experience


PC-02 Cesarean Section (Provider Level) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3788)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: Duplicative of measure under consideration X3768 that is already in use in private programs.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, outcome measure that fills a gap area? and provides more measures for obstetricians.

Measure development status: Fully developed

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? Yes.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? No. A similar measure underconsideration X3768 Primary C-section rate 2014 from MNCM is already in use in provate programs in MN.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. The facility-level measure for hospitals is endorsed by NQF.

Rationale for measure provided by HHS: This AMA – PCPI measure is harmonized with the Joint Commission’s measure (PC-02 Cesarean Section) in language and intent. The Joint Commission measure is a facility-level measures whereas this measure includes attribution at the individual provider level measure Cesarean deliveries are performed for many reasons. Some, such as those for breech presentation, are supported by strong clinical consensus. However, many cesareans, especially those done in the course of labor, are the result of labor management practices that vary widely and suggest clinician discretion (CMQCC) There is growing evidence to support the claim that provider-dependent indications (i.e., those that rely on provider judgment) combined with provider discretion contribute significantly to the overall increase in both primary and repeat cesareans. The fact that cesarean delivery rates and practices vary widely among states, regions, hospitals, and providers for both primary and repeat cesareans demonstrates that hospitals and clinicians can differ in their responses to the same conditions. This fact suggests the need for more precise clinical practice guidelines and/or greater accountability and incentives for following them. (California Maternal Quality Care Collaborative) California Maternal Quality Care Collaborative clinician interviews (funded by California HealthCare Foundation) reveal that many nurses talked about the timing of cesareans done during labor, citing the competing demands on physicians for clinic appointments and their desire for balance between work and the rest of life. Institutional pressures and the pace of high-volume facilities was another factor mentioned, along with physicians’ impatience with labor progress—a response that can be exacerbated in clinicians and mothers alike by the use of inductions, which can set up an expectation for a quick birth experience


Pediatric Kidney Disease: Discussion of Care Planning for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3733)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Pediatric care coordination measure. Important for dual eligibles.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority of focusing on patient- and family-centered care;

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Also tested at individual practice; group practice level

Is the measure currently in use? No. QCDR

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: Institute family-centered care planning for children and adolescents with CKD and ESRD. The plan should establish treatment goals based on a child’s medical condition and prognosis. (RPA, 2010) Care planning should be an ongoing process in which treatment goals are determined and revised based on observed benefits and burdens of dialysis and the values of the pediatric patient and the family. The renal care team should designate a person to be primarily responsible for ensuring that care planning is offered to each patient. Patients with decision-making capacity should be strongly encouraged to talk to their parents to ensure that they know the patient’s wishes and agrees to make decisions according to these wishes. Ongoing discussions that include reestablishing goals of care based on the child’s response to medical treatment and optimal quality of life is the mechanism by which care planning occurs. Discussions should include pros and cons of dialysis as well as potential morbidity associated with dialysis. Kidney transplantation should also be discussed if appropriate. (RPA, 2010)


Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3739)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This is a process measure of patients receiving a survey before and after the procedure. Suggest developing as a patient-reported outcome measure that compares the survey results before and after surgery.

Does the measure address a critical program objective as defined by MAP? Yes. This process measure assesses use of a patient reported outcome survey but the results are not used as a PRO outcome measure.

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? Yes. No level of analysis indicated, however measure can be applied at the clinical level to assess the number of treatements rendered and surveys provided by a clinician.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignment due to lack of testing data and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: Surrogate measures for success of saphenous ablation have numerous flaws. The ultimate measure of success of saphenous ablation in patients with varicose veins is improved quality of life. This quality measure motivates physicians to assess quality of life after an ablation as compared with before an ablation to understand the improvement in quality of life that they offer their patients. Eventually, some threshold for improvement based on disease state may serve as a benchmark for quality care. The Intersocietal Accreditation Commission-Vein Center Division strongly recommends the use of the disease specific patient reported outcome (PRO) instrument before and after ablation and to use the data collected for an analysis of the quality of care being delivered by the center (1).These guidelines have been created by the IAC and are being implemented by several groups including SVS. 1. “Vein Center Accreditation A Process to Demonstrate a Commitment to Quality Vein Care.” March 11, 2014. http://www.veindirectory.org/magazine/article/vein_center_accreditation_a_process_to_demonstrate_a_commitment_to_quality_vein_care The American Venous Forum recommends the use of PRO before and after vein treatment for all patients (2). 2. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.” May 2011. http://www.bendvein.com/downloads/Journal-Vascular-Surgery.pdf


Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment for program(s): MSSP (MUC ID: X3739)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP. Preference for PROM with patient results.

Does the measure address a critical program objective as defined by MAP? No. Patient-reported process measure. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Surrogate measures for success of saphenous ablation have numerous flaws. The ultimate measure of success of saphenous ablation in patients with varicose veins is improved quality of life. This quality measure motivates physicians to assess quality of life after an ablation as compared with before an ablation to understand the improvement in quality of life that they offer their patients. Eventually, some threshold for improvement based on disease state may serve as a benchmark for quality care. The Intersocietal Accreditation Commission-Vein Center Division strongly recommends the use of the disease specific patient reported outcome (PRO) instrument before and after ablation and to use the data collected for an analysis of the quality of care being delivered by the center (1).These guidelines have been created by the IAC and are being implemented by several groups including SVS. 1. “Vein Center Accreditation A Process to Demonstrate a Commitment to Quality Vein Care.” March 11, 2014. http://www.veindirectory.org/magazine/article/vein_center_accreditation_a_process_to_demonstrate_a_commitment_to_quality_vein_care The American Venous Forum recommends the use of PRO before and after vein treatment for all patients (2). 2. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.” May 2011. http://www.bendvein.com/downloads/Journal-Vascular-Surgery.pdf


Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3755)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Measure of follow-up after procedure performed by interventional radiologists.

Does the measure address a critical program objective as defined by MAP? Yes. A measure for follow-up of prior procedure for interventional radiologists.

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? Yes. No level of analysis indicated, however measure can be applied at the clinical level to assess the number of treatements rendered and surveys provided by a clinician.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? No. No assessment of alignement due to lack of testing and performance information.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. N/A

Rationale for measure provided by HHS: Retrievable filter complications have been increasingly noted in the FDA MAUDE database and in the literature. Retrievable filters were designed differently than permanent filters and the incidence of device related complications with long term insertions are higher than in comparison to permanent filters. The FDA has recommended that physicians that place these filters, carefully monitor these patients and remove these filters at the earliest possible time. The proposed quality measure will encourage physicians who place filters to follow-up with their patients at 3 months and document that a decision has been made to either a) remove the filter, b) document that re-assessment has established the appropriateness of continued filter use or c) documentation of at least two attempts to reach the patient, proxy or primary care provider to arrange a clinical re-assessment for the appropriateness of filter removal. Dedicated follow-up for IVC filters has led to an increase in retrieval rate (1). FDA recommends that all physicians placing IVC Filters and those responsible for ongoing care of these patients, remove the filter as soon as protection from PE is no longer needed. The FDA encourages follow-up on patients to consider risks and benefits of filter removal (2,3,4). Data on IVC Filters will be collected through the PRESERVE trial which is sponsored by teh IVC Filter Study Group Foundation. This trial will look at commercially available IVC Filters (retrievable) from participating manufacturers. The study objective is to evaluate the safety and effectiveness of participating IVC Filters in subjects with clinical need for mechanical prophylaxis of PE. 1. Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 2. “Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Uses.” August, 9, 2010. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm221707.htm 3. “Removing Retrievable Inferior Vena Cava Filters: Initial Communication.” August 9, 2010. http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm221676.htm Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 4. “Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication.” Amy 6, 2014. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm


Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal for program(s): MSSP (MUC ID: X3755)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important appropriateness measure. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Retrievable filter complications have been increasingly noted in the FDA MAUDE database and in the literature. Retrievable filters were designed differently than permanent filters and the incidence of device related complications with long term insertions are higher than in comparison to permanent filters. The FDA has recommended that physicians that place these filters, carefully monitor these patients and remove these filters at the earliest possible time. The proposed quality measure will encourage physicians who place filters to follow-up with their patients at 3 months and document that a decision has been made to either a) remove the filter, b) document that re-assessment has established the appropriateness of continued filter use or c) documentation of at least two attempts to reach the patient, proxy or primary care provider to arrange a clinical re-assessment for the appropriateness of filter removal. Dedicated follow-up for IVC filters has led to an increase in retrieval rate (1). FDA recommends that all physicians placing IVC Filters and those responsible for ongoing care of these patients, remove the filter as soon as protection from PE is no longer needed. The FDA encourages follow-up on patients to consider risks and benefits of filter removal (2,3,4). Data on IVC Filters will be collected through the PRESERVE trial which is sponsored by teh IVC Filter Study Group Foundation. This trial will look at commercially available IVC Filters (retrievable) from participating manufacturers. The study objective is to evaluate the safety and effectiveness of participating IVC Filters in subjects with clinical need for mechanical prophylaxis of PE. 1. Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 2. “Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Uses.” August, 9, 2010. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm221707.htm 3. “Removing Retrievable Inferior Vena Cava Filters: Initial Communication.” August 9, 2010. http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm221676.htm Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic Jeet Minocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu, Robert J. Lewandowski Journal of Vascular and Interventional Radiology - December 2010 (Vol. 21, Issue 12, Pages 1847-1851, DOI: 10.1016/j.jvir.2010.09.003) 4. “Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication.” Amy 6, 2014. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm


Performing an intraoperative rectal examination at the time of prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3740)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient safety process measure may have less value than the adverse outcome measure (X3744). Consider pairing the process and outcome measure. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Outcome measure; Clinically relevant to urologists; addresses NQS priority of focusing on making care safer by reducing harm caused in the delivery of care.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested at individual and group practice level

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: 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 an intraoperative rectal examination at the time of prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3740)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3752)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: NQF-endorsed patient safety process measure to identify and correct potential complications during surgery. Recommend pairing with the outcome measure X3743 when developed.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure for detection of a potential adverse outcomes.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure tested at individual and group practice levels.

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. This measure #2063 was endorsed in November, 2014.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

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).


Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3752)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary:

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).


Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E0465)

Full Measure Specifications

NQF Number (if applicable): 0465

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Support

Preliminary analysis summary: NQF-endorsed measure. Evidence-based process measure that promotes secondary prevention of vasular disease beyond the timeframe of surgery. Complements two outcome measures for this procedure.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure closely related to long-term outcomes; care coordination for secondary prevention of vascular disease.

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. Society of Vascular Surgery provides feeedback to participants.  The reigstry target for this measure is 90%.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Clinician-level measure.

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 Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: E0465)

Full Measure Specifications

NQF Number (if applicable): 0465

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3809)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Intermediate outcome measure revised from a prior process measure. Additional measure for anesthesia. Recommend clarification of the specifications as discussed with the NQF Surgery Standing Committee in May 2014 as the measure is further developed and tested.

Does the measure address a critical program objective as defined by MAP? Yes. This is an outcome measure that satisfies a gap area in its' assessment of body temperature in relation to anesthesia administration.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No program use information available.

Does the measure promote alignment and parsimony? . No assessment of alignment due to lack of testing data and peformance inforamtion.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure was reviewed by NQF Surgery Committee in May 2014. Many question about the specifications promptin gthe measure steward to withdraw the measure from consideration.

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.


Perioperative Temperature Management [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3809)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


Photodocumentation of cecal intubation for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3761)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure captures the completenss of the colonoscopy procedures used for screening and surveillence for colorectal cancer. Suggest a composite measure to combine multiple measures of colonoscopy performance.

Does the measure address a critical program objective as defined by MAP? Yes. This measure captures the completeness of the colonoscopy procedure.

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? N/A.

Is the measure currently in use? No. N/A

Does the measure promote alignment and parsimony? No.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy. Effective colonoscopists should be able to intubate the cecum in > 90% of cases, and in > 95% of cases when the indication is screening in a healthy adult. Studies have shown that physicians do not routinely document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon – from the rectum to the cecum. Knowing the depth of insertion can inform physicians of whether a radiographic procedure or repeat colonoscopy is necessary. However, the lack of comprehensive documentation can lead to unnecessary or repeat tests.


Photodocumentation of cecal intubation for program(s): MSSP (MUC ID: X3761)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Important measure regarding colonoscopy adequacy. Composite measure regarding adequacy of colonoscopy could be appropriate for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Measure reflects adequacy of colonoscopy.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy. Effective colonoscopists should be able to intubate the cecum in > 90% of cases, and in > 95% of cases when the indication is screening in a healthy adult. Studies have shown that physicians do not routinely document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon – from the rectum to the cecum. Knowing the depth of insertion can inform physicians of whether a radiographic procedure or repeat colonoscopy is necessary. However, the lack of comprehensive documentation can lead to unnecessary or repeat tests.


Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3794)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not support

Preliminary analysis summary: This plan of care measure does not add much to measure X3771 and X3772 that discuss acute and preventive treatment.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a gap in measurement for speciality providers.?

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Measure fully tested. No notes on level or setting tested.

Is the measure currently in use? No. Measure not noted to be in use in other programs.

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by allowing the participating of specality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Optimizing headache management requires a systematic assessment of symptoms, including the development of an individualized plan of care. Clinicians are advised to base their treatment choice on degree of disability along with attack frequency and duration, non-headache symptoms, patient preference, and prior history of treatment response, using a stratified approach to care. This information should be included in the patient’s plan of care. HRQoL and disability are positively impacted by treatment interventions and a continuity of care.


Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed for program(s): MSSP (MUC ID: X3794)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure in gap area. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Optimizing headache management requires a systematic assessment of symptoms, including the development of an individualized plan of care. Clinicians are advised to base their treatment choice on degree of disability along with attack frequency and duration, non-headache symptoms, patient preference, and prior history of treatment response, using a stratified approach to care. This information should be included in the patient’s plan of care. HRQoL and disability are positively impacted by treatment interventions and a continuity of care.


Plan Of Care Or Referral For Possible Medication Overuse Headache for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3784)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: This process measure follows up on the screening for medication overuse in MUC X3783. Consider pairing the measures. Conditional on testing at the clincian-level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure; addresses NQS priority - promoting the most effective prevention and treatment practices; high value measure - addresses patient safety.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired, or a two-part measure, that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III medication overuse headache criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose.


Plan Of Care Or Referral For Possible Medication Overuse Headache for program(s): MSSP (MUC ID: X3784)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondary headaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent and often at its worst on awakening. This is a paired, or a two-part measure, that is scored separately for part A and part B. The measure 6A focuses on assessing for MOH using the July 2013 ICHD-III medication overuse headache criteria. In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan of care created by the clinician or the clinician should refer the patient for this purpose.


Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3810)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for realiability and valdiity and meaningful differences among anesthesia providers will be important.

Does the measure address a critical program objective as defined by MAP? Yes. An additional measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is currently being used in PQRS (Qualified Clinical Data Registry Option) then it should easily align with the established objectives for inclusion in the other 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: 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 Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3810)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3807)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Process measure for use of a checklist or protocol for care coordination as a patient is transferred from anesthesia providers to others post-operatively. This measure may be more applicable to the facility as protocols typically apply to all providers. Testing for reliability and valdity and meaningful differences among anesthesia providers will be important.

Does the measure address a critical program objective as defined by MAP? Yes. Another measure for anesthesia.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is currently being used in PQRS (Qualified Clinical Data Registry Option) then it should easily align with the established objectives for inclusion in the other 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: 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.


Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3807)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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 assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3746)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. Process measure that contrbutes to approrpiate use of surgery.

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: When a woman with pelvic organ prolapse experiences urinary leakage only when the prolapse is reduced, her condition is called an occult stress urinary incontinence. The underlying cause may be urethral compression or urethral kinking. The percentage of patients in whom evidence of occult stress urinary incontinence is discovered prior to prolapse surgery varies from 23 to 69%. According to the guidelines of the German society of obstetrics and gynecology, a stress test with and without reduction of the prolapse should be conducted prior to prolapse surgery . Guidelines of the International Continence Society go even further, stating urodynamic investigations with and without stress test should be included in the diagnostic workup of patients prior to prolapse surgery. While several studies have shown improved urinary incontinence rates following prolapse surgery that included an anti-incontinence component, the potential risks of adding another procedure must be considered as well. A systematic review and meta-analysis of randomized trials concluded that in the group of women with occult stress urinary incontinence there is a lower incidence of objective stress urinary incontinence after combined (prolapse+sling) surgery 22% versus 52% with no difference in bladder storage symptoms, urgency incontinence, and long-term obstructive voiding symptoms. However, to benefit from this data and to support good decision-making, the surgeon must determine whether there is or isn't occult stress incontinence preoperatively. In a recent study we found that 78.6% of patients had a pre-operative stress test and that 93.5% of high volume surgeons evaluated their patients for occult prior to surgery for pelvic organ prolapse while 63% of low volume surgeons and 72% of intermediate volume surgeons did.


Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3746)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: This measure addresses a gap in speciality measurement. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. The measure fills a gap in speciality care measurement. Does not address MSSP program objectives.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Measure being specified and tested?

Is the measure currently in use? No. Measure not yet used in any programs.Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? ?This measure promotes alignment by involving specialities in program reporting..

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: When a woman with pelvic organ prolapse experiences urinary leakage only when the prolapse is reduced, her condition is called an occult stress urinary incontinence. The underlying cause may be urethral compression or urethral kinking. The percentage of patients in whom evidence of occult stress urinary incontinence is discovered prior to prolapse surgery varies from 23 to 69%. According to the guidelines of the German society of obstetrics and gynecology, a stress test with and without reduction of the prolapse should be conducted prior to prolapse surgery . Guidelines of the International Continence Society go even further, stating urodynamic investigations with and without stress test should be included in the diagnostic workup of patients prior to prolapse surgery. While several studies have shown improved urinary incontinence rates following prolapse surgery that included an anti-incontinence component, the potential risks of adding another procedure must be considered as well. A systematic review and meta-analysis of randomized trials concluded that in the group of women with occult stress urinary incontinence there is a lower incidence of objective stress urinary incontinence after combined (prolapse+sling) surgery 22% versus 52% with no difference in bladder storage symptoms, urgency incontinence, and long-term obstructive voiding symptoms. However, to benefit from this data and to support good decision-making, the surgeon must determine whether there is or isn't occult stress incontinence preoperatively. In a recent study we found that 78.6% of patients had a pre-operative stress test and that 93.5% of high volume surgeons evaluated their patients for occult prior to surgery for pelvic organ prolapse while 63% of low volume surgeons and 72% of intermediate volume surgeons did.


Preoperative assessment of sexual function prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3742)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in speciality measurement.

Measure development status: Fully developed

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? N/A. N/A

Is the measure currently in use? No. Measure not used in programs

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by involving speciality providers in program reporting

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? No.

Rationale for measure provided by HHS: Since surgeries to correct urinary incontinence and pelvic organ prolapse in women aim to improve quality of life, it is also important to assess sexual function, which affects quality of life and often improves after these types of surgeries. By assessing preoperative sexual function, we will be able to assess if sexual function is regained, improves, or worsens after these types of surgeries. Because urinary incontinence and pelvic organ prolapse tend to occur in middle age, these are modifiable conditions that can be successfully treated and contribute to healthy aging and improved quality of life.


Preoperative assessment of sexual function prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3742)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

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? No.

Rationale for measure provided by HHS: Since surgeries to correct urinary incontinence and pelvic organ prolapse in women aim to improve quality of life, it is also important to assess sexual function, which affects quality of life and often improves after these types of surgeries. By assessing preoperative sexual function, we will be able to assess if sexual function is regained, improves, or worsens after these types of surgeries. Because urinary incontinence and pelvic organ prolapse tend to occur in middle age, these are modifiable conditions that can be successfully treated and contribute to healthy aging and improved quality of life.


Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3741)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GYN and GU specialists. Conditional on submission to NQF. Suggest developing a more high-value composite measure of all required preoperative evaluations in MUCs X3751, X3746, X3741, X3742.

Does the measure address a critical program objective as defined by MAP? Yes. Patient safety measure to exclude possibility of cancer before proceeding with surgery. A cancer diagnosis would indicate a different approach to the surgery.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Being tested at individual and group practice level.

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 measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to hysterectomy and can be referred to a gynecologic oncologist for appropriate staging and treatment for the malignancy. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). In a recent review of 63 robotic-assisted supracervical hysterectomies with sacrocervicopexies for pelvic organ prolapse, 2 patients (3.2%) were found on final pathology to have endometrial carcinoma.. Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.


Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair for program(s): MSSP (MUC ID: X3741)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? .

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? No.

Rationale for measure provided by HHS: This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to hysterectomy and can be referred to a gynecologic oncologist for appropriate staging and treatment for the malignancy. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). In a recent review of 63 robotic-assisted supracervical hysterectomies with sacrocervicopexies for pelvic organ prolapse, 2 patients (3.2%) were found on final pathology to have endometrial carcinoma.. Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.


Preoperative pessary for pelvic organ prolapse attempted for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3745)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GU. Unclear the benefit of two pessary measures (also X3750 pessary offered). Consider composite of both measures for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Fills a gap in measurement for GU.

Measure development status: Fully developed

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? N/A. N/A

Is the measure currently in use? No. Not currently in use.

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by involving specialties.

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? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 38% (219/575) of patients actually tried a pessary with their surgeon before being operated on for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse attempted for program(s): MSSP (MUC ID: X3745)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 38% (219/575) of patients actually tried a pessary with their surgeon before being operated on for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse offered for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3750)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Additional process measure for GU for alternative to surgery. Unclear the benefit of two pessary measures (also X3745 pessary attempted). Consider composite of both measures for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. This measure fills a gap in measurement for GU. Non-surgical alternative prior to surgery.

Measure development status: Fully developed

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? N/A. N/A

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. Measure promotes alignment by addressing gaps in specality measurement.

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? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 77% (443/575) of surgeons offered their patients a pessary prior to surgery for pelvic organ prolapse.


Preoperative pessary for pelvic organ prolapse offered for program(s): MSSP (MUC ID: X3750)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: Important clinician-only level measure. Does not relate to MSSP program objectives.

Does the measure address a critical program objective as defined by MAP? No. Narrow measure related to single condition. Does not relate to MSSP program objectives.

Measure development status: Fully developed

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? Yes.

Is the measure currently in use? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected (Obstet and Gynecol 2004; 104: 489-96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGS members, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931-5. Experts note that it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852-60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147-147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201-6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 77% (443/575) of surgeons offered their patients a pessary prior to surgery for pelvic organ prolapse.


Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3808)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Evidence-based, preoperative process of care measure. Additional measure for anesthesia.

Does the measure address a critical program objective as defined by MAP? Yes. Evidence-based treatment related to improved patient outcomes.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing for use in Hospital/Acute Care Facility, in beta testing.LOA Tested: Clinician: Individual; Clinician: Group/Practice; Clinician: Team; Facility

Is the measure currently in use? Yes. PQRS only.

Does a review of its performance history raise any concerns? 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: 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.


Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3808)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


Prescription of HIV Antiretroviral Therapy for program(s): MSSP (MUC ID: E2083)

Full Measure Specifications

NQF Number (if applicable): 2083

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Not broadly applicable to Medicare FFS population, though could be appropriate for duals population. Prefer outcome measure for HIV (e.g., viral suppression)

Does the measure address a critical program objective as defined by MAP? No. Though HIV can occur at any age, more prevalent in patients < 35 years. May not be appropriate for general FFS population; could be appropriate for duals population

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? Yes. Finalized Public Programs: Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? . Yes

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? No.

Rationale for measure provided by HHS: Prescription of HIV antiretroviral therapy is a critical component of the HIV care continuum. Although HIV viral suppression is the ultimate outcome of HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap-around supportive services within HIV care.


Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3806)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This process measure includes evaluation of risk for PONV and adminstration of appropriate preventive medications.

Does the measure address a critical program objective as defined by MAP? Yes. This measure satisfies a gap area in its' assessment of patients with post-operative nausea and vomiting (PONV) who receive combination therapy. This measure also promotes participation among eligible professionals.

Measure development status: Field testing

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? Yes. Measure in use in the PQRS Program under the Qualified Clinical Data Registry Option.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. If this measure is in use under: PQRS (Qualified Clinical Data Registry Option) then it should align with the established objectives for other 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: 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.


Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3806)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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.


Prevention Quality Indicators #90 (PQI #90) for program(s): MSSP (MUC ID: X3715)

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Requires testing at ACO level. Need to consider appropriateness of conditions within composite for Medicare FFS population.

Does the measure address a critical program objective as defined by MAP? Yes. Appropriate use measure for hospitalization. Not all conditions relevant for Medicare FFS population.

Measure development status: Fully developed

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? Yes. Requires testing at ACO level

Is the measure currently in use? State level. Finalized Public Programs: Federal Programs Under Consideration: Medicare Shared Savings ProgramPrivate:

Does the measure promote alignment and parsimony? Composite of multiple potentially avoidable hospitalizations.. No

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: Addresses prevention and is a composite with PQIs already in program.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): MSSP (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Population screening for alcohol dependence; support development for PRS and EHR Incentive also.

Does the measure address a critical program objective as defined by MAP? Yes. Screening for important condition in Medicare population.

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? Finalized Public Programs: Physician Feedback;#Physician Quality Reporting System (PQRS)Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? Also support development for PQRS and EHR Incentive programs..

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Recent NQF maintenance review reocmmends continued endorsement of this revised measure that now includes follow-up after a positive screen.

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 intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009. This measure is also duplicative of composite MUC X3475 as alcohol screening is one of the components.

Does the measure address a critical program objective as defined by MAP? Yes. Population screening with follow-up measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. During NQF-endorsement review testing using automated EHR reports as well as through manual chart abstraction was reviewed. CMS has determined that all EHR measure are being updated to most current EHR specification standards.?

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. The measure was tested at the ambulatory level.

Is the measure currently in use? Yes. An abbreviated version of this measure (which focuses only on the screening for unhealthy alcohol use component of the measure and not the brief counseling component) was included in PQRS from 2009.

Does a review of its performance history raise any concerns? No. Recent data for mean performance of the measure is as follows:- 2009: 31.0% among 1,876 eligible professionals submitting- 2010: 63.2% among 4,635 eligible professionals submitting 

Does the measure promote alignment and parsimony? Yes. The abbreviated version of this measure is already in use in PQRS.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. The measure was evaluated by the Behavioral Health Steering Committee in 2014. The Committee agreed the the impact of screening and brief counseling on unhealthy alcohol use is well documented and that gaps in care exist. The Committee voted overwhelming

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 intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling for program(s): MUEP (MUC ID: E2152)

Full Measure Specifications

NQF Number (if applicable): 2152

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Do not encourage further consideration

Preliminary analysis summary: See PQRS measure.

Does the measure address a critical program objective as defined by MAP? Yes. Complements existing population screening measure with broad appllicability.

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.

Does the measure promote alignment and parsimony? Yes. Would fill a gap in an important screening topic area.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Recent NQF review and continued endorsement recommended.

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 intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al., 2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico et al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify--substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of these heavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third-leading cause of preventable deaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three-quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment. This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence.


Preventive Migraine Medication Prescribed for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3772)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure of appropriate preventive treatment for patients with frequent migraines. Conditional on testing at the clincian-level and submission for NQF endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Measure of appropriate preventive treatment for patients with frequent migraines.

Measure development status: Fully developed

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? N/A.

Is the measure currently in use? No.

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 measure is designed to address the strong gap in care in the use of prophylactic medication for migraine headache. Migraine is suboptimally treated in the majority of patients. Note: this measure does not specifically address chronic migraine or MRM.


Preventive Migraine Medication Prescribed for program(s): MSSP (MUC ID: X3772)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: This measure is designed to address the strong gap in care in the use of prophylactic medication for migraine headache. Migraine is suboptimally treated in the majority of patients. Note: this measure does not specifically address chronic migraine or MRM.


Primary C-Section Rate 2014 for program(s): MSSP (MUC ID: X3768)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important measure. Not appropriate for Medicare population.

Does the measure address a critical program objective as defined by MAP? No. Important appropriateness measure. Not relevant to Medicare FFS population

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? No. Finalized Public Programs: Federal Programs Under Consideration: Medicare and Medicaid EHR Incentive Program for Eligible Professionals;#Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Rationale for measure provided by HHS: The growing support for the claim that provider-dependent indications are contributing to the overall increase among cesareans can be seen from the results of two recent studies examining the drivers for the increase in cesarean deliveries. Barber et al. (2011) at Yale analyzed primary and repeat cesareans from 2003 to 2009. Among primary cesarean deliveries, more subjective indications (non-reassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions). Similarly, Getahun et al. (2009) examined the causes for the rise in cesarean deliveries among different racial and ethnic groups in Kaiser Permanente Southern California over the last 17 years. Their findings were similar to those from Yale. In a retrospective cohort study conducted by Ehrenthal et al. (2010), labor induction was associated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. This was more pronounced among a low-risk group of women without major complications. Beyond the medical burden to mothers and babies, the financial burden on payers is large: facility charges for cesarean are nearly twice that for vaginal delivery ($24,700 vs. $14,500). In California alone, the additional heath care costs to the system are conservatively estimated to be over $300 million annually (Main et al., 2011) The most frequent causes of severe maternal morbidity are obstetric hemorrhage (bleeding) and uterine infection. These are significantly more common with cesarean surgery and also represent the two leading causes of hospital readmission in the first 30 days post-delivery. A recent CDC analysis showed that the rate of severe obstetric hemorrhage has significantly increased (by 50%) over the last 15 years in the U.S. There has also been a 270% increase in blood transfusions, with both hemorrhage and transfusions correlated to the rise in cesarean deliveries. Infection is the most common serious complication of cesarean delivery with typical rates of 3 to 9% (Kuklina et al., 2009). The American College of Obstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate (ACOG, 2000).


Primary C-Section Rate 2014 for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3768)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Outcome measure important to consumers in use in Minnesota. First public reports aredue in late 2014. Fills a gap in perinatal measures.

Does the measure address a critical program objective as defined by MAP? Yes. High-value measure: outcome; submitted by Consumer Purchaser Alliance; few current measure for obstetricians

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Piloted in MN for clinciain groups; recommended for use in state-wide reporting

Is the measure currently in use? Yes. Measure specifications and instructions for the program available at: http://mncm.org/wp-content/uploads/2014/05/C-section_Data_Collection_Guide_FINAL-5.8.2014.pdf 

Does a review of its performance history raise any concerns? No. No performance data - first public reporting due late 2014

Does the measure promote alignment and parsimony? Yes. Duplicate measure:X3788 (claims); 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. NQF had endiorsed the hospital -level measure from the Joint Commission that is closely related to this measure.

Rationale for measure provided by HHS: The growing support for the claim that provider-dependent indications are contributing to the overall increase among cesareans can be seen from the results of two recent studies examining the drivers for the increase in cesarean deliveries. Barber et al. (2011) at Yale analyzed primary and repeat cesareans from 2003 to 2009. Among primary cesarean deliveries, more subjective indications (non-reassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions). Similarly, Getahun et al. (2009) examined the causes for the rise in cesarean deliveries among different racial and ethnic groups in Kaiser Permanente Southern California over the last 17 years. Their findings were similar to those from Yale. In a retrospective cohort study conducted by Ehrenthal et al. (2010), labor induction was associated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. This was more pronounced among a low-risk group of women without major complications. Beyond the medical burden to mothers and babies, the financial burden on payers is large: facility charges for cesarean are nearly twice that for vaginal delivery ($24,700 vs. $14,500). In California alone, the additional heath care costs to the system are conservatively estimated to be over $300 million annually (Main et al., 2011) The most frequent causes of severe maternal morbidity are obstetric hemorrhage (bleeding) and uterine infection. These are significantly more common with cesarean surgery and also represent the two leading causes of hospital readmission in the first 30 days post-delivery. A recent CDC analysis showed that the rate of severe obstetric hemorrhage has significantly increased (by 50%) over the last 15 years in the U.S. There has also been a 270% increase in blood transfusions, with both hemorrhage and transfusions correlated to the rise in cesarean deliveries. Infection is the most common serious complication of cesarean delivery with typical rates of 3 to 9% (Kuklina et al., 2009). The American College of Obstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate (ACOG, 2000).


Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3743)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on sumission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. High-value adverse outcome measure. approximately 200,000 inpatient surgical procedures for prolapse are performed annually in US. 11- 19%  of women will undergo surgery for prolapse or incontinence by age 80 to 85 years. The incidence of urinary tract in

Measure development status: Fully developed

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? N/A. N/A

Is the measure currently in use? Yes. Measure is used in the Australian Council on Healthcare Standards

Does a review of its performance history raise any concerns? No. No performance data available

Does the measure promote alignment and parsimony? Yes. Measure promotes alignment by involving specialities in program participation.

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? No.

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 bladder injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3743)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3744)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Adverse outcome measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? The measure is currently being tested.

Is the measure currently in use? Yes. Used in the Australian Council on Healthcare Standards

Does a review of its performance history raise any concerns? No. Performance data unavailable

Does the measure promote alignment and parsimony? Yes. This measure promotes alignment by involving specalities in program reporting.

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? No.

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 major viscus injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3744)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: 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): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3813)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: High-value adverse outcome measure for GU and GYN surgeons performing pelvic organ prolapse surgeries. Suggest composite adverse outcome measure with MUC X3743, X3813, X3744 for parsimony. Conditional on submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. Adverse outcome measure.

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. Measure in use by the Australian Council on Healthcare Standards.

Does a review of its performance history raise any concerns? . No performance information available.

Does the measure promote alignment and parsimony? Yes. While there are currently no measures within PQRS that address the topic-are this measure covers, inclusion of this measure in the program could promote development of additional measures to evaluate ureter injuries related to pelvic organ prolapse repai

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.


Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair [Measure referred from hospital workgroup] for program(s): MSSP (MUC ID: X3813)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary:   Conditional Support pending NQF review and endorsement

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.


Quality Of Life Assessment For Patients With Primary Headache Disorders for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3786)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Patient reported outcome measure for quality of life in patients with headaches. Conditional on testing at the clincian-level and submission to NQF for endorsement.

Does the measure address a critical program objective as defined by MAP? Yes. Patient reported outcome measure.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Fully developed and tested.

Is the measure currently in use? No. Measure not used in other programs.

Does the measure promote alignment and parsimony? Yes.

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? No.

Rationale for measure provided by HHS: This measure establishes an initial or baseline QoL score from which the patient should use the same QoL tool/questionnaire at least one additional time during the measurement period. The two assessments must be separated by at least 90 days for MIDAS and at least 4 weeks for any other tool. It is expected that the QoL score or ranking will stay the same or improve in order for this measure to be successfully completed.


Quality Of Life Assessment For Patients With Primary Headache Disorders for program(s): MSSP (MUC ID: X3786)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Important PROM appropriate for clinician level measurement; may be too narrow for MSSP.

Does the measure address a critical program objective as defined by MAP? Yes. Patient reported outcome measure for single condition.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: This measure establishes an initial or baseline QoL score from which the patient should use the same QoL tool/questionnaire at least one additional time during the measurement period. The two assessments must be separated by at least 90 days for MIDAS and at least 4 weeks for any other tool. It is expected that the QoL score or ranking will stay the same or improve in order for this measure to be successfully completed.


Rate of surgical conversion from lower extremity endovascular revascularization procedure for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3754)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: High-value adverse outcome measure for interventional radiologists.

Does the measure address a critical program objective as defined by MAP? Yes. This is a high-value, adverse outcome measure for interventioal radiologists.

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? N/A. No level of analysis indicated.

Is the measure currently in use? No.

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: Conversions from a planned lower extremity endovascular revascularization procedure to a surgical procedure indicates either poor patient assessment/procedural assignment, or procedural failure. This represents a patient care quality measure. Patients who undergo unplanned surgical conversion have a higher cost of care and higher morbidity and mortality. There is a higher expense for dual procedures, with use of endovascular tools and surgical procedural time and equipment, as well as longer length of stay and rehabilitation. Studies show higher rates of limb salvage in patients with foot ulcers after surgical or catheter based restoration of arterial blood flow than with medical therapy alone, but there is insufficient robust data to indicate better outcomes with endovascular or open bypass treatment of arterial insufficiency in this patient group. (1) Both amputation-free survival and quality of life outcomes have been shown to be comparable for patients with critical limb ischemia treated with either open bypass or endovascular repair, but the bypass-first strategy has been shown to be more costly. (2) There are many studies suggesting benefit of an endovascular-first approach to limb salvage because of the proposed patient benefits, including ability to avoid general anesthesia for these procedures, avoidance of a surgical incision and attendant healing time, shorter length of hospital stay with endovascular revascularization when compared to bypass, strong patient preference for endovascular approaches, and decreased cost of a successful endovascular approach. Although long term limb salvage outcomes are equivalent regardless of the initial strategy adopted, some data indicate a high rate of early technical failure of endovascular treatment of critical limb ischemia, but high secondary patency rates and high limb conservation rates in spite of initial technical failures, indicating that repeat procedures, both endovascular and open, tend to be successful in this patient group. A meta-analysis of 30 studies of below knee angioplasty showed a higher technical failure rate of endovascular treatment than that seen with open (bypass) repair. (3) This same meta-analysis reports that repeat procedures in patients with endovascular-first failures were more likely to be bypass procedures than repeated endovascular procedures. Another study of 1023 patients undergoing either endovascular or open surgical treatment for critical limb ischemia demonstrated a higher rate of secondary surgical procedures in the endovascular group compared with the surgical group, but again showed comparable 5 year limb salvage rates in the two groups. (4) Notably, it has been demonstrated that the difference in patency rates and differences in rates of conversion to bypass appear to be partly related to the specialty of the operator, based on studies of procedural failure and open conversion rates in different physician groups. Two large studies of extracted data, one of Medicare claims data assessing mortality, transfusion rates, intensive care unit use, length of stay, and subsequent repeat revascularization procedures or amputation (5), and one of National Inpatient Sample (NIS) data reviewing in-hospital mortality and iatrogenic arterial injuries (6), showed statistically significant differences in outcomes across physician groups. One of these studies (Zafar, et al) suggested that there may be a higher use of repeat intervention, including adjunctive, unplanned surgical bypass, and a higher rate of amputation following a primary endovascular procedure in some physician cohorts. The reasons for this discrepancy are unclear, and may represent patient selection, operator bias towards endovascular revascularization in all comers, technical ability, or other factors. The newly-approved NHLBI trial, Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia, proposes to look at outcomes, including open conversions and amputations, in a cohort of patients randomized to open vs endovascular therapy. This trial will be multidisciplinary, evaluating all specialists involved in procedural care of this group of patients, and will ultimately provide guidance for physicians in terms of patient assignment to open vs endovascular care, and will establish solid data to support thresholds for conversion and amputation. However, data will not be available for years to come. This measure proposes, based on the data available in the existing literature, to track use of repeat or unplanned adjunctive surgical (bypass or amputation) procedures in patients undergoing revascularization procedures for lower extremity arterial insufficiency. It is expected that this rate should be equivalent across all physician groups performing endovascular procedures when adjusted for specific patient risk factors. With establishment of a baseline benchmark rate for conversion to surgical therapy based on existing data from the Medicare sample, rates of conversion may be tracked to encourage appropriate patient selection or referral to expert operators to improve patient outcomes and reduce excessive resource use by selection of the most appropriate procedure and procedural operator. 1. Hinchliffe RJ et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metabolism Research and Reviews 2012; 28(Suppl. 1):179-217. 2. Adam DJ et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet 2005;366:1925-34. 3. Romiti M, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975-81. 4. Söderström MI et al. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis. Annals of Surgery 2010;252:765-773. 5. Zafar AM et al. Lower-Extremity Endovascular Interventions for Medicare Beneficiaries: Comparative Effectiveness as a Function of Provider Specialty, J Vasc Interv Radiol 2012; 23:3–9. 6. Eslami MH et al. Peripheral arterial interventions: Trends in market share and outcomes by specialty, 1998-2005; J Vasc Surg 2009;50:1071-8.


Rate of surgical conversion from lower extremity endovascular revascularization procedure for program(s): MSSP (MUC ID: X3754)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not encourage further consideration for MSSP

Preliminary analysis summary: Important clinician-only level measure. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: Conversions from a planned lower extremity endovascular revascularization procedure to a surgical procedure indicates either poor patient assessment/procedural assignment, or procedural failure. This represents a patient care quality measure. Patients who undergo unplanned surgical conversion have a higher cost of care and higher morbidity and mortality. There is a higher expense for dual procedures, with use of endovascular tools and surgical procedural time and equipment, as well as longer length of stay and rehabilitation. Studies show higher rates of limb salvage in patients with foot ulcers after surgical or catheter based restoration of arterial blood flow than with medical therapy alone, but there is insufficient robust data to indicate better outcomes with endovascular or open bypass treatment of arterial insufficiency in this patient group. (1) Both amputation-free survival and quality of life outcomes have been shown to be comparable for patients with critical limb ischemia treated with either open bypass or endovascular repair, but the bypass-first strategy has been shown to be more costly. (2) There are many studies suggesting benefit of an endovascular-first approach to limb salvage because of the proposed patient benefits, including ability to avoid general anesthesia for these procedures, avoidance of a surgical incision and attendant healing time, shorter length of hospital stay with endovascular revascularization when compared to bypass, strong patient preference for endovascular approaches, and decreased cost of a successful endovascular approach. Although long term limb salvage outcomes are equivalent regardless of the initial strategy adopted, some data indicate a high rate of early technical failure of endovascular treatment of critical limb ischemia, but high secondary patency rates and high limb conservation rates in spite of initial technical failures, indicating that repeat procedures, both endovascular and open, tend to be successful in this patient group. A meta-analysis of 30 studies of below knee angioplasty showed a higher technical failure rate of endovascular treatment than that seen with open (bypass) repair. (3) This same meta-analysis reports that repeat procedures in patients with endovascular-first failures were more likely to be bypass procedures than repeated endovascular procedures. Another study of 1023 patients undergoing either endovascular or open surgical treatment for critical limb ischemia demonstrated a higher rate of secondary surgical procedures in the endovascular group compared with the surgical group, but again showed comparable 5 year limb salvage rates in the two groups. (4) Notably, it has been demonstrated that the difference in patency rates and differences in rates of conversion to bypass appear to be partly related to the specialty of the operator, based on studies of procedural failure and open conversion rates in different physician groups. Two large studies of extracted data, one of Medicare claims data assessing mortality, transfusion rates, intensive care unit use, length of stay, and subsequent repeat revascularization procedures or amputation (5), and one of National Inpatient Sample (NIS) data reviewing in-hospital mortality and iatrogenic arterial injuries (6), showed statistically significant differences in outcomes across physician groups. One of these studies (Zafar, et al) suggested that there may be a higher use of repeat intervention, including adjunctive, unplanned surgical bypass, and a higher rate of amputation following a primary endovascular procedure in some physician cohorts. The reasons for this discrepancy are unclear, and may represent patient selection, operator bias towards endovascular revascularization in all comers, technical ability, or other factors. The newly-approved NHLBI trial, Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia, proposes to look at outcomes, including open conversions and amputations, in a cohort of patients randomized to open vs endovascular therapy. This trial will be multidisciplinary, evaluating all specialists involved in procedural care of this group of patients, and will ultimately provide guidance for physicians in terms of patient assignment to open vs endovascular care, and will establish solid data to support thresholds for conversion and amputation. However, data will not be available for years to come. This measure proposes, based on the data available in the existing literature, to track use of repeat or unplanned adjunctive surgical (bypass or amputation) procedures in patients undergoing revascularization procedures for lower extremity arterial insufficiency. It is expected that this rate should be equivalent across all physician groups performing endovascular procedures when adjusted for specific patient risk factors. With establishment of a baseline benchmark rate for conversion to surgical therapy based on existing data from the Medicare sample, rates of conversion may be tracked to encourage appropriate patient selection or referral to expert operators to improve patient outcomes and reduce excessive resource use by selection of the most appropriate procedure and procedural operator. 1. Hinchliffe RJ et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metabolism Research and Reviews 2012; 28(Suppl. 1):179-217. 2. Adam DJ et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet 2005;366:1925-34. 3. Romiti M, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975-81. 4. Söderström MI et al. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis. Annals of Surgery 2010;252:765-773. 5. Zafar AM et al. Lower-Extremity Endovascular Interventions for Medicare Beneficiaries: Comparative Effectiveness as a Function of Provider Specialty, J Vasc Interv Radiol 2012; 23:3–9. 6. Eslami MH et al. Peripheral arterial interventions: Trends in market share and outcomes by specialty, 1998-2005; J Vasc Surg 2009;50:1071-8.


Risky Behavior Assessment or Counseling by Age 13 Years for program(s): MUEP (MUC ID: E1406)

Full Measure Specifications

NQF Number (if applicable): 1406

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Suggest broadening the age range and combing this measure with E1507 Risky Behavior Assessment or Counseling by age 18 years.

Does the measure address a critical program objective as defined by MAP? Yes. Additional measure for specialists in adolescent care.

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? No. The non-EHR measure was endorsed by NQF but the steward has retired it due to lack of use.

Does the measure promote alignment and parsimony? .

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Non-EHR measure retired from endorsement by the steward due to lack of use.

Rationale for measure provided by HHS: NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment or counseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessment or Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity. Early alcohol and drug use (pre-adolescent/early adolescent) is a predictor of later dependence. In the 2003 National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15 were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately 58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s. Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral Health Coordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reports separate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 the BHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is more likely to see their doctor without their parent, which promotes more honest conversations. References: 2010-2011 National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm


Risky Behavior Assessment or Counseling by Age 18 Years for program(s): MUEP (MUC ID: E1507)

Full Measure Specifications

NQF Number (if applicable): 1507

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Suggest broadening the age range and combining with measure E1406 for parsimony.

Does the measure address a critical program objective as defined by MAP? Yes. Addiitonal measure for specialists in adolescent care.

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? No. Non-EHR measure retired by the steward for lack of use.

Does the measure promote alignment and parsimony? No. Would combine with measure under consideration E1406 for parsimony.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Non-EHR measure was endorsed, but has been retired by the measure steward for lack of use.

Rationale for measure provided by HHS: NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment or counseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessment or Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity. Early alcohol and drug use (pre-adolescent/early adolescent) is a predictor of later dependence. In the 2003 National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15 were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately 58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s. Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral Health Coordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reports separate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 the BHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is more likely to see their doctor without their parent, which promotes more honest conversations. References: 2010-2011 National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm


Scoliosis Evaluation Ordered for program(s): MSSP (MUC ID: X3798)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Do not support for MSSP

Preliminary analysis summary: Important clinician-only level measure in gap area. Does not meet objectives for MSSP.

Does the measure address a critical program objective as defined by MAP? No. Clinically important measure. Does not address MSSP program objectives.

Measure development status: Fully developed

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. Finalized Public Programs: Federal Programs Under Consideration: Medicare Physician Quality Reporting System (PQRS);#Medicare Shared Savings Program;#Physician Compare;#Physician Feedback/Quality and Resource Utilization Reports;#Physician Value-Based Payment Modifier ProgramPrivate:

Does the measure promote alignment and parsimony? . No

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? No.

Rationale for measure provided by HHS: There is a risk of evolving musculoskeletal spine deformities, such as scoliosis, kyphosis, or rigid spine syndrome, in various dystrophies. These musculoskeletal deformities can result in discomfort and functional impairment, interfering with gait, activities of daily living, and pulmonary function. The proper management of musculoskeletal spine deformities is important in order to reduce discomfort, preserve mobility or ability to sit in a wheelchair, and reduce pulmonary complications.


Scoliosis Evaluation Ordered for program(s): PQRS/Physician Compare/Physician Feedback/VBPM (MUC ID: X3798)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Quality Reporting System (PQRS) ; Physician Compare; Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Scoliosis, or spinal curvature, is common in patients with Duchenne's muscular dystrophy. Early detection and surgery can aid breathing, lessen back pain and improve sitting balance. Conditional on testing at the clinician level and submission to NQF.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses a gap in the measurement of specialty care (neurology).

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The level of testing is not noted.

Is the measure currently in use? No. Not in use in other programs.

Does the measure promote alignment and parsimony? Yes. The measure promotes alignment by encouraging the participation of specality providers.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. Not endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is a risk of evolving musculoskeletal spine deformities, such as scoliosis, kyphosis, or rigid spine syndrome, in various dystrophies. These musculoskeletal deformities can result in discomfort and functional impairment, interfering with gait, activities of daily living, and pulmonary function. The proper management of musculoskeletal spine deformities is important in order to reduce discomfort, preserve mobility or ability to sit in a wheelchair, and reduce pulmonary complications.


Spine Fusion/ Refusion Clinical Episode-Based Payment Measure for program(s): Physician Feedback/VBPM (MUC ID: X0353)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Physician Feedback; Value-Based Payment Modifier

Preliminary analysis result: Conditional support

Preliminary analysis summary: Quality measure are needed for spine surgery to match this cost measure.

Does the measure address a critical program objective as defined by MAP? Yes. Cost measures required for VBPM.

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: 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)).


Statin Therapy for the Prevention and Treatment of Cardiovascular Disease for program(s): MUEP (MUC ID: X3729)

Full Measure Specifications

NQF Number (if applicable):

Programs under consideration: Medicare and Medicaid EHR Incentive Programs

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Aligns with PQRS.

Does the measure address a critical program objective as defined by MAP? Yes. Align with PQRS.

Measure development status: Early development

Is the measure fully tested for the program's setting